Development of a Novel Care Rehabilitation Pathway for Post-COVID Conditions (Long COVID) in a Provincial Health System in Alberta, Canada

OBJECTIVE

The purpose of this study was to describe the development and composition of a codesigned, multidisciplinary, integrated, systematic rehabilitation framework for post-COVID conditions (PCC) that spans the care continuum to streamline and standardize rehabilitation services to support persons with PCC in Alberta, Canada.

METHODS

A collaborative, consensus-based approach was used involving 2 iterative provincial taskforces in a Canadian provincial health system. The first taskforce (59 multidisciplinary stakeholders) sought to clarify the requisite facets of a sustainable, provincially coordinated rehabilitation approach for post-COVID rehabilitation needs based on available research evidence. The second taskforce (129 multidisciplinary stakeholders) translated that strategy and criteria into an operational framework for provincial implementation. Both taskforces sought to align with operational realities of the provincial health system.

RESULTS

The summation of this collaborative consensus approach resulted in the Provincial Post COVID-19 Rehabilitation Response Framework (PCRF). The PCRF includes 3 care pathways across the care continuum specifically targeting in-hospital care, continuing care, and community-based care with 3 key elements: (1) the use of specific symptom screening and assessment tools to systematically identify PCC symptoms and functional impairments, (2) pathways to determine patients' rehabilitation trajectory and guide their transition between care settings, and (3) self-management and education resources for patients and providers.

CONCLUSION

The PCRF aligns with international mandates for novel, codesigned, multidisciplinary approaches to systematically address PCC and its myriad manifestations across the care continuum. The PCRF allows for local adaptation and highlights equity considerations, allowing for further spread and scale provincially, nationally, and internationally.

IMPACT

The PCRF is a framework for health systems to ensure consistent identification, assessment, and management of the rehabilitation needs of postacute and chronic PCC. Rehabilitation providers and health systems can build from the PCRF for their local communities to reduce unmet needs and advance the standardization of access to rehabilitation services for persons with PCC.

Development of a complex intervention to improve mobility and participation of older people with vertigo, dizziness and balance disorders in primary care: a mixed methods study

BACKGROUND

Vertigo, dizziness and balance disorders (VDB) are common in older people and cause restrictions in mobility and social participation. Due to a multifactorial aetiology, health care is often overutilised, but many patients are also treated insufficiently in primary care. The purpose of this study was to develop a care pathway as a complex intervention to improve mobility and participation in older people with VDB in primary care.

METHODS

The development process followed the UK Medical Research Council guidance using a mixed-methods design with individual and group interviews carried out with patients, physical therapists (PTs), general practitioners (GPs), nurses working in community care and a multi-professional expert panel to create a first draft of a care pathway (CPW) and implementation strategy using the Consolidated Framework of Implementation Research and the Expert recommendations for Implementing Change. Subsequently, small expert group modelling of specific components of the CPW was carried out, with GPs, medical specialists and PTs. The Behaviour Change Wheel was applied to design the intervention´s approach to behaviour change. To derive theoretical assumptions, we adopted Kellogg´s Logic Model to consolidate the hypothesized chain of causes leading to patient-relevant outcomes.

RESULTS

Individual interviews with patients showed that VDB symptoms need to be taken more seriously by GPs. Patients demanded age-specific treatment offers, group sessions or a continuous mentoring by a PT. GPs required a specific guideline for diagnostics and treatment options including psychosocial interventions. Specific assignment to and a standardized approach during physical therapy were desired by PTs. Nurses favoured a multi-professional documentation system. The structured three-day expert workshop resulted in a first draft of CPW and potential implementation strategies. Subsequent modelling resulted in a CPW with components and appropriate training materials for involved health professionals. A specific implementation strategy is now available.

CONCLUSION

A mixed-methods design was suggested to be a suitable approach to develop a complex intervention and its implementation strategy. We will subsequently test the intervention for its acceptability and feasibility in a feasibility study accompanied by a comprehensive process evaluation to inform a subsequent effectiveness trial.

TRIAL REGISTRATION

The research project is registered in "Projektdatenbank Versorgungsforschung Deutschland" (Project-ID: VfD_MobilE-PHY_17_003910; date of registration: 30.11.2017).

Clinical Pathway for Emergency Brain Surgery during COVID-19 Pandemic and Its Impact on Clinical Outcomes

BACKGROUND

One of the challenges neurosurgeons are facing in the global public health crisis caused by the coronavirus disease 2019 (COVID-19) pandemic is to balance COVID-19 screening with timely surgery. We described a clinical pathway for patients who needed emergency brain surgery and determined whether differences in the surgery preparation process caused by COVID-19 screening affected clinical outcomes.

METHODS

During the COVID-19 period, patients in need of emergency brain surgery in our institution were managed using a novel standardized pathway designed for COVID-19 screening. We conducted a retrospective review of patients who were hospitalized through the emergency room and underwent emergency brain surgery. A total of 32 patients who underwent emergency brain surgery from February 1 to June 30, 2020 were included in the COVID-19 group, and 65 patients who underwent surgery from February 1 to June 30, 2019 were included in the pre-COVID-19 group. The baseline characteristics, disease severity indicators, time intervals of emergency processes, and clinical outcomes of the two groups were compared. Subgroup analysis was performed between the immediate surgery group and the semi-elective surgery group during the COVID-19 period.

RESULTS

There were no significant differences in baseline characteristics and severity indicators between the pre-COVID-19 group and COVID-19 group. The time interval to skin incision was significantly increased in the COVID-19 group (P = 0.027). However, there were no significant differences in the clinical outcomes between the two groups. In subgroup comparison, the time interval to skin incision was shorter in the immediate surgery group during the COVID-19 period compared with the pre-COVID-19 group (P = 0.040). The screening process did not significantly increase the time interval to classification and admission for immediate surgery. The time interval to surgery initiation was longer in the COVID-19 period due to the increased time interval in the semi-elective surgery group (P < 0.001).

CONCLUSION

We proposed a clinical pathway for the preoperative screening of COVID-19 in patients requiring emergency brain surgery. No significant differences were observed in the clinical outcomes before and after the COVID-19 pandemic. The protocol we described showed acceptable results during this pandemic.

The impact of a post-operative clinical care pathway on head and neck microvascular free tissue transfer outcomes

OBJECTIVE

To study the impact of a clinical care pathway and computerised order set on short-term post-operative outcomes for patients undergoing head and neck free tissue transfer.

METHODS

In this retrospective cohort study, patients who underwent head and neck free tissue transfer by a single reconstructive surgeon between January 2007 and July 2009 were assigned to one of two cohorts based on the timing of their surgery: pre- or post-clinical care pathway implementation. Measured outcomes included peri-operative complications and mortality, length of hospital stay and costs, unplanned reoperations, and readmissions within 30 days of discharge.

RESULTS

The pre-clinical care pathway cohort included 81 patients and the post-clinical care pathway cohort comprised 46. Implementation of the clinical care pathway was associated with decreased variability in length of hospital stay (median (interquartile range) = 8 (6, 11) vs 7 (6, 9) days). The post-clinical care pathway cohort also had a significantly lower unplanned reoperation rate (15.2 vs 35.8 per cent, p = 0.01).

CONCLUSION

A clinical care pathway is a successful means of standardising and improving complex patient care. In this study, care pathway implementation in head and neck free tissue transfer patients improved efficiency and the quality of patient care.

Development of a Graphical Interface to Visualize and Analyze the Pathways of Patients During Their Hospital Stay for Thoracic Surgery

The multidisciplinary aspect of patient care is not yet sufficiently taken into account in hospital ward management. By gathering data from the administrative database of hospital stays and the operating theaters management software, we developed a graphical user interface to visualize and analyze the pathways of patients who underwent thoracic surgery in the Nantes University Hospital of France in 2016 and 2017.

Patient and Health Care Professional Perspectives: A Case Study of the Lung Cancer Integrated Care Pathway

Introduction:

The purpose of this study was to evaluate the perception of the quality of care, considering both patient experience and health care professionals’ perceptions as well as patient outcome measures of an integrated lung cancer pathway.

Methods:

A cross-sectional study was conducted in 2016 at Ferrara University Hospital, Italy. OPportunity for Treatment In ONcology (OPTION) questionnaires were administered to 77 patients, and the Care Process Self-Evaluation Tool (CPSET) questionnaires were given to 38 health care professionals. The effectiveness of the pathway was evaluated by analysing the tool’s positive impact on lung cancer surgery volume and 30-day mortality.

Results:

Seventy-seven patients were enrolled, and 38 health care professionals assessed the CPSET questionnaire. The highest scores were related to “respect” (100%), “satisfaction” (98.7%), and “trust” (97.4%) on the OPTION and to “patient-focused vision” (97.2%) and “patient engagement” (94.4%) on the CPSET. The lowest scores were related to “information” (26%) and “cooperation with general practitioner” (17.6%) on the OPTION and “cooperation between the hospital and primary care” (23.5%) for the CPSET. The outcomes analysis shows an increase in the volume of activity and a decrease in 30-day mortality after pathway implementation.

Discussion:

The lung cancer pathway is a patient-centred intervention that enables care to be shaped for patient needs in order to improve the quality and efficiency of service and clinical outcome.

Care Pathway for Cancer Survivorship in Korea: Trend of Breast Cancer Pathway from 2003 to 2010

Objectives

The survival rate of cancer patients has exceeded 60%. Although cancer survivors may die of other diseases except cancer, the health management system including chronic disease prevention-management for cancer survivors, has not been established in the diverse aspects. Therefore, services according to care pathway of cancer patients need to be provided through a support system based on a platform concept that can be used to meet patient needs in various ways.

Methods

A sample cohort database (2002–2010) of approximately 1 million persons—2% of the whole nation (50 million)—was used to estimate cancer survivors through a principal care pathway for cancer management. The sample cohort database was built to estimate the number of breast cancer survivors in the five stage: ‘Diagnosis and treatment,’ ‘Supportive care,’ ‘Monitoring,’ ‘Progress illness,’ and ‘Hospice care’. In this way, the scale of breast cancer survivors was estimated.

Results

There were 330 (9.8%) cases of the incidence of cancer in 2010 in the ‘Diagnosis and treatment.’ Among the cases of the incidence of cancer in the previous year, the number of one-year survivors was 328 (9.7%); these were included in the category ‘Supportive care.’ In the ‘Monitoring’ category, 2,593 (76.9%) who maintained health lives were included. A total of 84 (2.5%) survivors were checked to identify an ongoing disease; these were included in the category ‘Progress illness.’ In the category ‘Hospice care,’ 36 (1.1%) end-stage cancer patients requiring hospice care were included.

Conclusions

We established a care pathway by survival stage in order to fulfill prevention and health management services post-treatment management steps.

An Interactive Platform to Visualize Data-Driven Clinical Pathways for the Management of Multiple Chronic Conditions

Patients with multiple chronic conditions (MCC) pose an increasingly complex health management challenge worldwide, particularly due to the significant gap in our understanding of how to provide coordinated care. Drawing on our prior research on learning data-driven clinical pathways from actual practice data, this paper describes a prototype, interactive platform for visualizing the pathways of MCC to support shared decision making. Created using Python web framework, JavaScript library and our clinical pathway learning algorithm, the visualization platform allows clinicians and patients to learn the dominant patterns of co-progression of multiple clinical events from their own data, and interactively explore and interpret the pathways. We demonstrate functionalities of the platform using a cluster of 36 patients, identified from a dataset of 1,084 patients, who are diagnosed with at least chronic kidney disease, hypertension, and diabetes. Future evaluation studies will explore the use of this platform to better understand and manage MCC.

Graph Clustering System for Text-Based Records in a Clinical Pathway

The progressive digitization of medical records has resulted in the accumulation of large amounts of data. Electronic medical data include structured numerical data and unstructured text data. Although text-based medical record processing has been researched, few studies contribute to medical practice. The analysis of unstructured text data can improve medical processes. Hence, this study presents a clustering approach for detecting typical patient's condition from text-based medical record of clinical pathway. In this approach, the sentences in a cluster are merged to generate a "sentence graph" of the cluster after classified feature word by Louvain method. An analysis of real text-based medical records indicates that sentence graphs can represent the medical treatment and patient's condition in a medical process. This method could help the standardization of text-based medical records and the recognition of feature medical processes for improving medical treatment.

Conformance Analysis of Clinical Pathway Using Electronic Health Record Data

Objectives

The objective of this study was to confirm the conformance rate of the actual usage of the clinical pathway (CP) using Electronic Health Record (EHR) log data in a tertiary general university hospital to improve the CP by reflecting real-world care processes.

Methods

We analyzed the application and matching rates of clinicians' orders with predefined CP order sets based on data from 164 inpatients who received appendectomies out of all patients who were hospitalized from August 2013 to June 2014. We collected EHR log data on patient information, medication orders, operation performed, diagnosis, transfer, and CP order sets. The data were statistically analyzed.

Results

The average value of the actual application rate of the prescribed CP order ranged from 0.75 to 0.89. The application rate decreased when the order date was factored in along with the order code and type. Among CP pre-operation, intra-operation, post-operation, routine, and discharge orders, orders pertaining to operations had higher application rates than other types of orders. Routine orders and discharge orders had lower application rates.

Conclusions

This analysis of the application and matching rates of CP orders suggests that it is possible to improve these rates by updating the existing CP order sets for routine discharge orders to reflect data-driven evidence. This study shows that it is possible to improve the application and matching rates of the CP using EHR log data. However, further research should be performed to analyze the effects of these rates on care outcomes.

Early rehabilitation in head injury; can we improve the outcomes?

Background:

The quality of care after head injury is still very variable with a little coordination between different specialties. Acute care dominates, often with little regard to rehabilitation needs.

Objectives:

To improve the outcomes of all head injury admissions to hospital, including mild and moderate, by creating a head injury team to supervise a rehabilitation clinical pathway.

Patients and Methods:

A head injury team was established to manage the care of all non-neurosurgical admissions with head injury to a large teaching hospital. Apart from inpatient care, the team coordinates various services involved in the care of head injuries, arranged suitable follow-ups, supported relatives and trained healthcare staff on general wards in the treatment of head injured patients. Follow-up clinics at 6 weeks and 6 months were arranged.

Results:

In the first three years, the team managed the care of 812 admissions. Mean age was 44.3 years (SD = 24.8) and mean length of hospital stay was 6.1 days (SD = 10.9). Of these individuals, 674 attended for 6 month follow-up with 52.2% having a good outcome on Extended Glasgow outcome score. Patients and their relatives' feedbacks were excellent with an average score of 4.7/5 on overall satisfaction rating. Following presentations at national meetings and elsewhere, other centers in the United Kingdom are now setting up similar pathways.

Conclusions:

A dedicated clinical pathway and head injury team can improve the quality of care for all admissions with head injury and enhance the role for rehabilitation medicine input at an early stage.