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da Silva Ramos FJ, Freitas FGR, Machado FR. Boarding in the emergency department: challenges and mitigation strategies. Curr Opin Crit Care 2024; 30:239-245. [PMID: 38525875 DOI: 10.1097/mcc.0000000000001149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
PURPOSE OF REVIEW Herein, we conducted a review of the literature to better understand the issue of prolonged emergency department (ED) boarding by providing an overview of the current evidence on the available causes, consequences, and mitigation strategies. RECENT FINDINGS Severely ill patients awaiting transfer to intensive care units (ICU) imposes additional burdens on the emergency care team from both a clinical and management perspective. The reasons for prolonged ED boarding are multifactorial. ED boarding compromises patients' safety and outcomes, and is associated with increased team burnout and dissatisfaction. Mitigation strategies include the optimization of patients' flow, the establishment of resuscitative care units, deployment of mobile critical care teams, and improvements in training. Staffing adjustments, changes in hospital operations, and quality improvement initiatives are required to improve this situation, while active bed management and implementation of capacity command centers may also help. SUMMARY Considering the characteristics of healthcare systems, such as funding mechanisms, organizational structures, delivery models, access and quality of care, the challenge of ED boarding of critically ill patients requires a nuanced and adaptable approach. Solutions are complex but must involve the entirety of the hospital system, emergency department, staff adjustment, and education.
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Affiliation(s)
- Fernando J da Silva Ramos
- Intensive Care Department - Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
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Baker DW. Handoffs and Care Transitions: Interviews with Chris Landrigan and Theresa Murray. Jt Comm J Qual Patient Saf 2024; 50:377-384. [PMID: 38553378 DOI: 10.1016/j.jcjq.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
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Hyder S, Tang R, Huang R, Ludwig A, Scott K, Nadig N. Implementation of an Interdisciplinary Transfer Huddle Intervention for Prolonged Wait Times During Inter-ICU Transfer. Jt Comm J Qual Patient Saf 2024; 50:371-376. [PMID: 38378394 DOI: 10.1016/j.jcjq.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND ICU transfers from a regional to a tertiary-level hospital are initiated typically for a higher level of care. Extended transfer wait times can negatively affect survival, length of stay (LOS), and cost. METHODS In this prospective single-center study, the subjects were adult ICU patients admitted to regional hospitals between January and October 2022, for whom a request was made to transfer to a tertiary-level medical ICU. The authors developed and implemented an interdisciplinary transfer huddle intervention (THI) with the goal of reducing wait times by providing a consistent channel of communication between key stakeholders. The primary outcome was the number of hours elapsed between transfer request and the time of transfer to the tertiary hospital. Secondary outcomes included in-hospital mortality, discharge to home, ICU LOS, and hospital LOS. Data were abstracted from electronic health records and periods before (January to June 2022) and after (June to October 2022) the intervention were compared. Data were analyzed using logistic regression or negative binomial regression, adjusting for patient demographic and clinical characteristics. ICU fellows also completed a daily survey about barriers they perceived to the THI application. RESULTS During the study period, 76 patients were transferred. The THI was completed 75.0% of the time. There were no statistically significant differences in the primary and secondary outcomes before and after the intervention. The top perceived barriers to transfer were lack of physical beds (50.0%) and staffing limitations (37.5%). CONCLUSION The authors successfully developed and implemented a transfer huddle to ensure consistent interdisciplinary communication for patients being transferred between ICUs and identified barriers to such transfer. However, transfer times and patient outcomes were not significantly different after the change. Future studies should consider staffing challenges, hospital capacity, and the role of dedicated transfer teams in in decreasing inter-ICU transfer wait times.
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Parikh NR, Francisco LS, Balikai SC, Luangrath MA, Elmore HR, Erdahl J, Badheka A, Chegondi M, Landrigan CP, Pennathur P, Reisinger HS, Cifra CL. Development and Evaluation of I-PASS-to-PICU: A Standard Electronic Template to Improve Referral Communication for Interfacility Transfers to the Pediatric ICU. Jt Comm J Qual Patient Saf 2024; 50:338-347. [PMID: 38418317 DOI: 10.1016/j.jcjq.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers. METHODS I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians. RESULTS Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use. CONCLUSION I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice.
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Strum RP, Tavares W, Worster A, Griffith LE, Costa AP. Emergency department interventions that could be conducted in subacute care settings for patients with nonemergent conditions transported by paramedics: a modified Delphi study. CMAJ Open 2022; 10:E1-E7. [PMID: 35017171 PMCID: PMC8758169 DOI: 10.9778/cmajo.20210148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND As the number of patients with nonemergent conditions who are transported by paramedics continues to increase in Ontario, redirecting specific patients to subacute settings may be more beneficial and suitable for both patients and emergency departments. We aimed to evaluate whether emergency department interventions conducted on patients with nonemergent conditions who are transported by paramedics could be conducted in subacute health centres. METHODS We conducted a RAND/UCLA modified Delphi study in Ontario between Oct. 13 and Dec. 19, 2020. We used purposive sampling to recruit practising emergency and primary care physicians for an expert panel. We abstracted interventions given to adult patients with nonemergent conditions (18 yr of age or older) who were transported by paramedics to an emergency department from the National Ambulatory Care Reporting System (NACRS) database (Jan. 1, 2014, to Mar. 31, 2018). Participants in the expert panel rated the suitability of the 150 most frequently recorded emergency department interventions from the NACRS database, for completion in subacute health care centres. We set consensus at 70% agreement. RESULTS We invited 25 physician experts, 21 of whom consented to participate; 20 physicians completed round 1, and 18 physicians completed both rounds. After 2 rounds, consensus was reached on 146 (97.3%) interventions; 103 interventions (68.7%) were suitable for subacute centres, 43 (28.7%) for only the emergency department and 4 (2.6%) did not receive consensus. For subacute centres, all 103 interventions were rated for urgent care centres; walk-in medical centres were applicable for 46 (30.6%) interventions and clinics led by nurse practitioners for 47 (31.3%) interventions. INTERPRETATION Most interventions provided to patients with nonemergent conditions transported by paramedics to emergency departments were identified as suitable for urgent care clinics, with one-third being suitable for either walk-in medical centres or clinics led by nurse practitioners. This study has potential to inform a patient classification model for paramedic-initiated redirection of patients from emergency departments, although further contextualization is required for this to be implemented in clinical practice. STUDY REGISTRATION ID ISRCTN22901977.
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Affiliation(s)
- Ryan P Strum
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont.
| | - Walter Tavares
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont
| | - Andrew Worster
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact (Strum, Worster, Griffith, Costa), McMaster Institute for Research and Aging (Griffith), Emergency Medicine Division (Worster), Department of Medicine, and Department of Medicine (Costa), McMaster University, Hamilton, Ont.; The Wilson Centre (Tavares), University of Toronto, Toronto, Ont.; York Region Paramedic and Senior Services (Tavares), Regional Municipality of York, Newmarket, Ont
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Fang HY, Lee WC. Warning system improve the clinical outcomes in transfer patients with ST-segment elevation myocardial infarction. Medicine (Baltimore) 2021; 100:e26558. [PMID: 34190194 PMCID: PMC8257831 DOI: 10.1097/md.0000000000026558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/12/2021] [Indexed: 01/04/2023] Open
Abstract
A warning system included directly faxing electrocardiography information to the mobile phone immediately after an ST-segment elevation myocardial infarction (STEMI) diagnosis was made at a non-percutaneous coronary intervention (PCI) capable hospital. This study aimed to explore the outcomes after using a warning system in transfer STEMI patients.From October 2013 to December 2016, 667 patients experienced a STEMI event and received primary PCI at our institution. 274 patients who were divided into transfer group were transferred from non-PCI capable hospitals and connected to a first-line cardiovascular doctor by the warning system. Other 393 patients were divided into the non-transfer group.The transfer group still had a longer pain-to-reperfusion time and presented higher troponin-I level when compared with non-transfer group. There was no significant difference in the use of drug-eluting stent and procedural devices between non-transfer and transfer groups. The prevalence of different anti-platelet agents loading did not differ between non-transfer and transfer groups. Non-significant trend about higher prevalence of statin use was noted in transfer group (78.9% vs 86.1%, P = .058). The transfer group presented similar clinical short-term results regarding both cardiovascular and all-cause mortality when comparing with non-transfer group. The transfer group provided non-significant trend about lower one-year cardiovascular mortality (10.7% vs 6.2%, P = .052) and lower all-cause mortality (12.2% vs 6.9%, P = .026) when compared with non-transfer group. There was a significant difference in the Kaplan-Meier curve of 1-year cardiovascular mortality between the transfer group and the non-transfer group (P = .049).After using the warning system, the inter-facility transfer group had comparable outcomes even though a longer pain-to-reperfusion time and a higher peak troponin-I level when comparing with non-transfer group.
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Kim YJ, Hong JS, Hong SI, Kim JS, Seo DW, Ahn R, Jeong J, Lee SW, Moon S, Kim WY. The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016-2018. J Korean Med Sci 2021; 36:e172. [PMID: 34184436 PMCID: PMC8239427 DOI: 10.3346/jkms.2021.36.e172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/31/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. METHODS This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016-2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. RESULTS We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). CONCLUSION The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the first-transfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.
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Affiliation(s)
- Youn Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Seok Hong
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seok In Hong
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - June Sung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ryeok Ahn
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jinwoo Jeong
- Department of Emergency Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sungwoo Moon
- National Emergency Medical Center, National Medical Center, Seoul, Korea
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Schmiady MO, Hofmann M, Sromicki J, Halbe M, van Tilburg K, Aser R, Mestres CA, Maisano F, Ferrari E. Initiation of an inter-hospital extracorporeal membrane oxygenation transfer programme for critically ill patients with coronavirus disease 2019: bringing extracorporeal membrane oxygenation support to peripheral hospitals. Interact Cardiovasc Thorac Surg 2021; 32:812-816. [PMID: 33647975 PMCID: PMC7989441 DOI: 10.1093/icvts/ivaa326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/31/2020] [Accepted: 11/09/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) is a resource-intensive, highly specialized and expensive therapy that is often reserved for high-volume centres. In recent years, we established an inter-hospital ECMO transfer programme that enables ECMO implants in peripheral hospitals. During the pandemic, the programme was expanded to include ECMO support in selected critically ill patients with coronavirus disease 2019 (COVID-19). METHODS This retrospective single-centre study reports the technical details and challenges encountered during our initial experience with ECMO implants in peripheral hospitals for patients with COVID-19. RESULTS During March and April 2020, our team at the University Hospital of Zurich performed 3 out-of-centre ECMO implants at different peripheral hospitals. The implants were performed without any complications. The patients were transported by ambulance or helicopter. Good preparation and selection of the required supplies are the keys to success. The implant should be performed by a well-trained, seasoned ECMO team, because options are limited in most peripheral hospitals. CONCLUSIONS Out-of-centre ECMO implants in well-selected patients with COVID-19 is feasible and safe if a well-established organization is available and if the implantation is done by an experienced and regularly trained team.
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Affiliation(s)
- Martin O Schmiady
- Division of Cardiac Surgery, University Heart Center, University Hospital of Zurich, Zurich, Switzerland
| | - Michael Hofmann
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Juri Sromicki
- Division of Cardiac Surgery, University Heart Center, University Hospital of Zurich, Zurich, Switzerland
| | - Maximilian Halbe
- Division of Cardiac Surgery, University Heart Center, University Hospital of Zurich, Zurich, Switzerland
| | - Koen van Tilburg
- Division of Cardiac Surgery, University Heart Center, University Hospital of Zurich, Zurich, Switzerland
| | - Raed Aser
- Division of Cardiac Surgery, University Heart Center, University Hospital of Zurich, Zurich, Switzerland
| | - Carlos A Mestres
- Division of Cardiac Surgery, University Heart Center, University Hospital of Zurich, Zurich, Switzerland
| | - Francesco Maisano
- Division of Cardiac Surgery, University Heart Center, University Hospital of Zurich, Zurich, Switzerland
| | - Enrico Ferrari
- Division of Cardiac Surgery, University Heart Center, University Hospital of Zurich, Zurich, Switzerland
- Cardiovascular Surgery Unit, Cardiocentro Ticino, Lugano, Switzerland
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Fung JST, Wong S, Murthy S, Muttalib F. Hospital outcomes of children admitted to intensive care in British Columbia via interfacility transfer versus direct admission from 2015 to 2017: a descriptive analysis. CMAJ Open 2021; 9:E602-E606. [PMID: 34074634 PMCID: PMC8177907 DOI: 10.9778/cmajo.20200263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pediatric intensive care relies on having experienced and effective transport systems to transfer critically ill children to the appropriate centre for care. Our aim was to compare hospital outcomes among children admitted directly to a pediatric intensive care unit (PICU) with those of children transferred from another facility. METHODS We conducted a descriptive study using electronic medical records and the PICU database from the BC Children's Hospital. Patients admitted to the PICU from January 2015 to December 2017 were included. We excluded patients who were admitted electively, were admitted for recovery postoperatively, or had inconsistent or out-of-range addresses. We compared hospital mortality rates, use of mechanical ventilation within 24 hours of admission and length of PICU stay between children admitted directly from the BC Children's Hospital emergency department and those transferred from a referring institution. RESULTS During the study period, there were 870 unique admissions comprising 386 direct admissions and 484 transferred patients. Transported patients were younger, were more critically ill on presentation and required longer stays. The proportions of children who died and of children who required mechanical ventilation within 24 hours of admission were higher in the transported group than in the group admitted directly from the emergency department (8.3% v. 3.9%, p = 0.008, and 75.8% v. 58.0%, p < 0.001, respectively). INTERPRETATION Mortality rate and use of intensive care resources were higher among children who were transported. Further research is needed to examine the key factors driving the differences in outcomes, including the severity of illness on first presentation, transport team composition, and transport distance and duration.
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Affiliation(s)
- Jollee S T Fung
- Faculty of Medicine (Fung), University of British Columbia, Vancouver, BC; Schulich School of Medicine & Dentistry (Wong), University of Western Ontario, London, Ont.; Division of Critical Care, Department of Pediatrics (Murthy, Muttalib), University of British Columbia, Vancouver, BC; Centre for Global Child Health, Hospital for Sick Children (Muttalib), Toronto, Ont
| | - Sean Wong
- Faculty of Medicine (Fung), University of British Columbia, Vancouver, BC; Schulich School of Medicine & Dentistry (Wong), University of Western Ontario, London, Ont.; Division of Critical Care, Department of Pediatrics (Murthy, Muttalib), University of British Columbia, Vancouver, BC; Centre for Global Child Health, Hospital for Sick Children (Muttalib), Toronto, Ont
| | - Srinivas Murthy
- Faculty of Medicine (Fung), University of British Columbia, Vancouver, BC; Schulich School of Medicine & Dentistry (Wong), University of Western Ontario, London, Ont.; Division of Critical Care, Department of Pediatrics (Murthy, Muttalib), University of British Columbia, Vancouver, BC; Centre for Global Child Health, Hospital for Sick Children (Muttalib), Toronto, Ont
| | - Fiona Muttalib
- Faculty of Medicine (Fung), University of British Columbia, Vancouver, BC; Schulich School of Medicine & Dentistry (Wong), University of Western Ontario, London, Ont.; Division of Critical Care, Department of Pediatrics (Murthy, Muttalib), University of British Columbia, Vancouver, BC; Centre for Global Child Health, Hospital for Sick Children (Muttalib), Toronto, Ont.
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COVID-19 Impact on the Movement of Patients Poststroke to Rehabilitation Centers. J Nurs Care Qual 2021; 36:175. [PMID: 33661818 DOI: 10.1097/NCQ.0000000000000554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Varma S, Schinasi DA, Ponczek J, Baca J, Simon NJE, Foster CC, Davis MM, Macy M. A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine? J Pediatr 2021; 230:126-132.e1. [PMID: 33152370 DOI: 10.1016/j.jpeds.2020.10.070] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/13/2020] [Accepted: 10/28/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterize children who experienced interfacility emergency department (ED) transfers with discharge home, and identify care potentially amenable to telemedicine in lieu of transfer. STUDY DESIGN Retrospective cohort study (July 2016 to June 2017) of patients transferred from general EDs to an academic pediatric ED and discharged home. The primary outcome was care potentially amenable to telemedicine defined as pediatric emergency medicine (PEM) provider assessment without other in-person subspecialty evaluation, diagnostic evaluation available in a general ED (electrocardiogram, point-of-care, or urine tests), and/or referrals and medications available in a general ED. Analysis included descriptive and χ2 statistics. RESULTS Of the 1733 patients transferred, 529 (31%) were discharged home and 22% of those discharged home had care potentially amenable to telemedicine. Patients amenable to telemedicine were more likely to be <2 years old (32% vs 17%; P = .002) and to have neurologic (29% vs 17%; P = .005), respiratory (16% vs 4%; P < .001), or urinary (5% vs 1%; P = .004) diagnoses than those whose care was not. Eight in 10 patients received their entire diagnostic evaluation before transfer and one-half received only a PEM provider assessment. An additional 281 cases were evaluated by a subspecialist in person, received routine imaging, or routine interventions. CONCLUSIONS Children receiving care potentially amenable to telemedicine in lieu of transfer often received their entire diagnostic evaluation before transfer; PEM provider assessment was the mainstay of care after transfer. These findings have implications for informing telemedicine to improve access to PEM expertise and potentially decrease some interfacility transfers.
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Affiliation(s)
- Selina Varma
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Dana A Schinasi
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Telemedicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jacqueline Ponczek
- Division of Hospital-Based Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jacqueline Baca
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Norma-Jean E Simon
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Carolyn C Foster
- Department of Telemedicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Mary Ann & J. Milburn Smith Child Health Research, Outreach and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | - Matthew M Davis
- Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Mary Ann & J. Milburn Smith Child Health Research, Outreach and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | - Michelle Macy
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Telemedicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Vest JR, Unruh MA, Hilts KE, Sanner L, Jones J, Khokhar S, Jung HY. End user information needs for a SMART on FHIR-based automated transfer form to support the care of nursing home patients during emergency department visits. AMIA Annu Symp Proc 2021; 2020:1239-1248. [PMID: 33936500 PMCID: PMC8075455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Nursing home (NH) patients are extensive users of emergency department (ED) services. Problematically, poor information sharing and incomplete access to information complicates the delivery of care in EDs for NH patients. Paper-based transfer forms can support information sharing, but have significant limitations. Standards-based automated transfer-forms that leverage health information exchange data may address the limitations of paper-based forms and better support care delivery. This study developed a prototype SMART on FHIR automated transfer form for NH patients using priority data elements identified through individual interviews, a review of existing transfer forms, a targeted survey of end users, and a design workshop. Analyses were grounded in the 5 Rights of clinical decision support framework. The most valuable data elements included: emergency contact/healthcare proxy, current medication list, reason for transfer to the ED, baseline neurological state, and relevant diagnoses / medical history. The working prototype was successfully deployed within an Amazon Web Service environment.
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Affiliation(s)
- Joshua R Vest
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Mark A Unruh
- Weill Cornell Medical College, New York, NY, USA
| | - Katy Ellis Hilts
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Lindsey Sanner
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Joshua Jones
- Regenstrief Institute, Inc., Indianapolis, IN, USA
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Abstract
COVID-19 has necessitated alterations to the delivery of healthcare services. Modifications include those made to improve patient and healthcare worker safety such as the use of personal protective equipment. Pharmacy services, specifically pharmacy transitions of care services have not been immune to change which have brought along their own set of unique challenges to consider. This paper discusses how COVID-19 has impacted the delivery of pharmacy transitions of care services with real world examples from Sharp Grossmont Hospital and Hoag Memorial Hospital Presbyterian. Procedures implemented to minimize the spread and contraction of COVID-19 such as minimized patient contact and altered visitor policies have made it more challenging to obtain a best possible medication list the patient was taking prior to arrival to the hospital which has lead to an increased reliance on secondary sources to complete medication histories. Regarding discharge prescriptions, preference has shifted to the use of electronic vs. hard copy prescriptions, mail order, and utilization of med to bed programs and other hospital medication delivery services to limit patient contact in outpatient pharmacies. An improved effort to resolve medication acquisition issues prior to discharge utilizing patient assistance programs and other hospital programs to cover the cost of medications for COVID positive patients under certain circumstances has been seen. This paper highlights the important role pharmacists can play in providing effective communication, supporting continuity of care, and advocating for patient engagement and empowerment during transitions of care in the COVID-19 pandemic.
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Affiliation(s)
- Kristen A Herzik
- Clinical Sciences Department, Touro University California College of Pharmacy, 1310 Club Drive, Vallejo, CA, 94594, USA; Pharmacy Department, Sharp Grossmont Hospital, 5555 Grossmont Center Dr, La Mesa, CA, 91942, USA.
| | - Laressa Bethishou
- Pharmacy Practice Department, Chapman University School of Pharmacy, 9401 Jeronimo Rd, Irvine, CA, 92618, USA; Pharmacy Department, Hoag Memorial Hospital Presbyterian, 1 Hoag Dr, Newport Beach, CA, 92663, USA
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Abstract
Interhospital transfers play a key role in ensuring that patients receive necessary care. However, patients who are transferred between hospitals are a vulnerable population, and outcomes of transferred patients are suboptimal. Despite the critical nature of interhospital transfers, only limited effort has been dedicated to standardization and improvement of the transfer process. Studying and adapting quality improvement efforts directed at other transitions of care, particularly those that cross between different facilities and care teams "such as the transition from hospital to home or extended care facilities" may improve the care of surgical patients transferred between acute care institutions.
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Affiliation(s)
- Angela Ingraham
- Department of Surgery, University of Wisconsin-Madison, G5/342 CSC, 600 Highland Avenue, Madison, WI 53792, USA. https://twitter.com/AngieIngrahamMD
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204, USA.
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15
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Dahine J, Hébert PC, Ziegler D, Chenail N, Ferrari N, Hébert R. Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria. Crit Care Med 2020; 48:e1147-e1157. [PMID: 32858530 PMCID: PMC7493782 DOI: 10.1097/ccm.0000000000004624] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission. DATA SOURCES PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. STUDY SELECTION We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted. DATA EXTRACTION Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme. DATA SYNTHESIS One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria. CONCLUSIONS This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.
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Affiliation(s)
- Joseph Dahine
- Département de médecine spécialisée, Centre intégré de santé et services sociaux de Laval (CISSS de Laval), Hôpital Cité-de-la-Santé, Université de Montréal, Laval, QC, Canada
| | - Paul C. Hébert
- Département de médecine, Centre Hospitalier de l’Université de Montréal, Université de Montréal et Centre de Recherche, Montreal, QC, Canada
| | - Daniela Ziegler
- Bibliothèque, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | | | - Nicolay Ferrari
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Réjean Hébert
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montreal, QC, Canada
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16
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Hayden EM, Boggs KM, Espinola JA, Camargo CA, Zachrison KS. Telemedicine Facilitation of Transfer Coordination From Emergency Departments. Ann Emerg Med 2020; 76:602-608. [PMID: 32534835 PMCID: PMC7252127 DOI: 10.1016/j.annemergmed.2020.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 03/30/2020] [Accepted: 04/14/2020] [Indexed: 11/05/2022]
Abstract
STUDY OBJECTIVE Interhospital transfers are costly to patients and to the health care system. The use of telemedicine may enable more efficient systems by decreasing transfers or diverting transfers from crowded referral emergency departments (EDs) to alternative appropriate facilities. Our primary objective is to describe the prevalence of telemedicine for transfer coordination among US EDs, the ways in which it is used, and characteristics of EDs that use telemedicine for transfer coordination. METHODS We used the 2016 National Emergency Department Inventory-USA survey to identify telemedicine-using EDs. We then surveyed all EDs using telemedicine for transfer coordination and a sample of EDs using telemedicine for other clinical applications. We used a multivariable logistic regression model to identify characteristics independently associated with use of telemedicine for transfer coordination. RESULTS Of the 5,375 EDs open in 2016, 4,507 responded to National Emergency Department Inventory-USA (84%). Only 146 EDs used telemedicine for transfer coordination; of these, 79 (54%) used telemedicine to assist with clinical care for local admission, 117 (80%) to assist with care before transfer, and 92 (63%) for arranging transfer to a different hospital. Among telemedicine-using EDs, lower ED annual visit volume (odds ratio 5.87, 95% CI 2.79 to 12.36) was independently associated with use of telemedicine for transfer coordination. CONCLUSION Although telemedicine has potential to improve efficiency of regional emergency care systems, it is infrequently used for coordination of transfer between EDs. When used, it is most often to assist with clinical care before transfer.
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Affiliation(s)
- Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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Aviv U, Berl A, Haik J, Tessone A, Harats M. Standardization of Burn Patients Transfer: Implementation of a Transfer Request Form to Israel's National Burn Center. Isr Med Assoc J 2020; 11:700-703. [PMID: 33249791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Burn injuries are an extreme form of traumatic injury and are a global health issue. The Israeli National Burn Unit at the Sheba Medical Center, a tertiary level 1 trauma center and hence the national referral center, treats burn patients admitted both directly and referred from other medical centers. The transfer and handover of patients is a critical step in patient care. In Israel, to date, there is no standardized and accepted transfer request form for burn patients from one medical facility to another. OBJECTIVES To construct a transfer request form to be used in all future burn patient referrals. METHODS After reviewing publicly available international transfer forms and comparing them to the admission checklist used at our unit, a structured transfer request form was constructed. RESULTS After a pilot study period, testing the form in various scenarios and adapting it, the first standardized transfer form for burn patients in Israel in both English and Hebrew was implemented beginning May 2020. CONCLUSIONS Implementation of a standardized transfer process will improve communication between healthcare professionals to help maintain a continuum of care. We believe that implementation of a burn transfer form in all future referrals can standardize and assure better care for burn patients, thus improving overall patient care.
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Affiliation(s)
- Uri Aviv
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Berl
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Josef Haik
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
- College of Health and Medicine, University of Tasmania, Sydney, NSW, Australia
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Tessone
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moti Harats
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Institute for Health Research University of Notre Dame, Fremantle, Australia
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Yau J, Tang KC, Tan HL, Teo LT. COVID-19 and the Intensive Care Unit: Coordinating a Multisite Intensive Care Unit Ramp-up Strategy in Singapore. Ann Acad Med Singap 2020; 49:825-828. [PMID: 33283849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Joachim Yau
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Takahashi PY, Leppin AL, Hanson GJ. Hospital to Community Transitions for Older Adults: An Update for the Practicing Clinician. Mayo Clin Proc 2020; 95:2253-2262. [PMID: 32736941 DOI: 10.1016/j.mayocp.2020.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 01/16/2020] [Accepted: 02/04/2020] [Indexed: 01/17/2023]
Abstract
Spurred by changes in both population demographics and health care reimbursement, health care providers are responding by using new models to more fully support the posthospital transition. This paper reviews common models for posthospital transition and also describes the Mayo Clinic model for care transition. Models are designed with the intent of managing the cost of health care by reducing 30-day hospital readmissions and improving management of chronic disease. Meta-analyses have proved helpful in identifying the most effective program elements designed to reduce 30-day hospital readmissions. These elements include a bundled and multidisciplinary approach to best meet the needs of patients. Successful care teams also emphasize self-empowerment for both patients and caregivers. There are 2 general types of practice. In 1 model, introduced by Mary Naylor, an advanced-practice provider cares for the patient for a set period of time, which includes home visits. In the second model, introduced by Eric Coleman, a transitions coach, who can be an RN, a social worker, or a trained volunteer, serves as the health care coach, while improving self-efficacy. Both models have been successful. At Mayo Clinic, the Mayo Clinic Care Transitions program has encompassed a 7-year experience, using the services of an advanced practice provider. In previous studies, this model demonstrated a 20.1% (95% confidence interval [CI], 15.8 to 24.1%) decrease in 30-day readmission in controls compared with 12.4% (95% CI, 8.9 to 15.7%) in the control group. Although this model was successful in reducing 30-day readmissions, there was no difference between groups at 180 days. In patients experiencing the highest deciles of cost (8th decile), enrollment in a care transitions program reduced their overall cost by $2700. This cost savings was statistically significant. Both patients and caregivers participating in the program appreciated the home visits and felt more comfortable communicating at home.
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Affiliation(s)
- Paul Y Takahashi
- Division of Community Internal Medicine and Division of Geriatrics and Gerontology, Mayo Clinic, Rochester, MN; Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN.
| | - Aaron L Leppin
- Division of Health Care Policy and Research, Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Gregory J Hanson
- Division of Community Internal Medicine and Division of Geriatrics and Gerontology, Mayo Clinic, Rochester, MN; Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN
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20
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Sanjuan Menéndez E, Girón Espot P, Calleja Macho L, Rodríguez-Samaniego MT, Santana Román KE, Rubiera Del Fueyo M. Implementation of a protocol for direct stroke patient transfer and mobilization of a stroke team to reduce times to reperfusion. Emergencias 2020; 31:385-390. [PMID: 31777209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The timing of treatment is a key prognostic factor in stroke. Our hospital implemented a rapid-action time-to-intervention protocol to optimize reperfusion times. The protocol consisted of direct transfer of stroke-code patients to the scanner or angiosuite and mobilization of the stroke team. Our aim was to assess the impact of the protocol on times to reperfusion. We also sought to evaluate the feasibility and safety of including a stroke-team nurse and assess staff satisfaction with the protocol. MATERIAL AND METHODS Descriptive study of patients attended by the hospital stroke team between March 2015 and March 2018. Outcomes were compared to those for the previous period (February 2014 to February 2015). RESULTS Nine hundred three patients were attended under the rapid-action protocol; 502 of them (55.6%) underwent reperfusion. The median (interquartile range) door-to-needle or groin access times were 24 (18-33) minutes for fibrinolysis and 39 (20-75) minutes for thrombectomy. Both times were significantly shorter than in the earlier period (43 [31-66] and 93 [60-150] minutes, respectively; P<.001). Median duration of nurse attendance was 25 (20-32) minutes during the implementation period, and no problems of feasibility or safety appeared during nurse attendance. Twenty staff members (95%) reported that the rapid-action protocol increased their workload but they felt it warranted continued application. CONCLUSION Direct transfer of stroke patients for scanning or to the angiography suite, with nurse attendance, safely reduced reperfusion times.
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Affiliation(s)
| | - Pilar Girón Espot
- Unidad de Ictus, Hospital Universitari Vall d'Hebron, Barcelona, España
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21
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Hay GJ, Klonek FE, Parker SK. Diagnosing rare diseases: A sociotechnical approach to the design of complex work systems. Appl Ergon 2020; 86:103095. [PMID: 32342886 DOI: 10.1016/j.apergo.2020.103095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 02/25/2020] [Accepted: 03/04/2020] [Indexed: 06/11/2023]
Abstract
How do complex healthcare systems that are organised into distinct speciality areas achieve effective patient care transitions when patients present with a rare constellation of symptoms that affect multiple body systems? How do these patients challenge existing ways of organising tasks, clinical activities, and interdependent responsibilities? The current study applies a sociotechnical systems perspective to understand how these complex work design and care-related challenges were resolved by the Western Australian Undiagnosed Diseases Program. We conducted a two-year longitudinal, qualitative study of this program, conceived to improve the diagnosis and management of patients with rare, multi-system disorders by piloting a re-design of the local system of diagnostic work. Specifically, we (1) compared the configuration and effectiveness of the old system and the re-designed system; and (2) analysed the process of system re-design (i.e., the design, implementation, and operation of the program) in order to understand the factors that contributed to - or inhibited - its success. We discuss the theoretical and practical implications of our findings for effectively re-designing complex, trans-organisational work systems.
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Affiliation(s)
- Georgia J Hay
- The University of Western Australia Business School, 35 Stirling Hwy, Perth, WA, 6009, Australia; Centre for Transformative Work Design, The Future of Work Institute, Curtin University, 78 Murray Street, Perth, WA, 6000, Australia.
| | - Florian E Klonek
- Centre for Transformative Work Design, The Future of Work Institute, Curtin University, 78 Murray Street, Perth, WA, 6000, Australia
| | - Sharon K Parker
- Centre for Transformative Work Design, The Future of Work Institute, Curtin University, 78 Murray Street, Perth, WA, 6000, Australia
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22
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Olsen O, Greene A, Makrides T, Delport A. Large-Scale Air Medical Operations in the Age of Coronavirus Disease 2019: Early Leadership Lessons From the Front Lines of British Columbia. Air Med J 2020; 39:340-342. [PMID: 33012469 PMCID: PMC7203048 DOI: 10.1016/j.amj.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 11/24/2022]
Abstract
In late 2019, a novel coronavirus was identified as the cause of a cluster of atypical pneumonia cases in Wuhan, China. It subsequently spread throughout China and around the world, quickly becoming a public health emergency. In March 2020, the World Health Organization declared coronavirus disease 2019 a pandemic. This article explores the preparation and early experiences of a large Canadian critical care transport program during the coronavirus disease 2019 pandemic focused on 6 broad strategic objectives centered around staff welfare, regular and transparent communication, networking, evidenced-based approach to personal protective equipment, agile mission planning, and an expedited approach to clinical practice and policy updates and future state modeling.
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Affiliation(s)
- Ole Olsen
- Paramedic Practice Leader, Critical Care Paramedic, British Columbia Emergency Health Service.
| | - Adam Greene
- Unit Chief Vancouver Critical Care Team, Critical Care Paramedic, British Columbia Emergency Health Service
| | - Timothy Makrides
- Manager Critical Care Operations, Critical Care Paramedic, British Columbia Emergency Health Service; Graduate Research Student, Department of Paramedicine, School of Primary and Allied Health Care, Faculty of Medicine, Nursing & Health Science, Monash University, Melbourne, Victoria
| | - Aldon Delport
- Lecturer, School of Health Medical and Applied Sciences, Central Queensland University
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23
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Wooldridge AR, Carayon P, Hoonakker P, Hose BZ, Eithun B, Brazelton T, Ross J, Kohler JE, Kelly MM, Dean SM, Rusy D, Gurses AP. Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. Appl Ergon 2020; 85:103059. [PMID: 32174347 PMCID: PMC7309517 DOI: 10.1016/j.apergo.2020.103059] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 11/13/2019] [Accepted: 01/13/2020] [Indexed: 06/02/2023]
Abstract
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.
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Affiliation(s)
- Abigail R Wooldridge
- Department of Industrial and Enterprise Systems Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA.
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA; Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Peter Hoonakker
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Bat-Zion Hose
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA; Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Benjamin Eithun
- American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
| | - Thomas Brazelton
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joshua Ross
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jonathan E Kohler
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michelle M Kelly
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shannon M Dean
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Deborah Rusy
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ayse P Gurses
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA; Division of Health Sciences Informatics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Bloomberg School of Public Health and Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
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24
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Terrasi B, Arnaud E, Guilbart M, Besserve P, Mahjoub Y. French ICUs fight back: An example of regional ICU organisation to tackle the SARS-CoV-2 outbreak. Anaesth Crit Care Pain Med 2020; 39:355-357. [PMID: 32360980 PMCID: PMC7191292 DOI: 10.1016/j.accpm.2020.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Benjamin Terrasi
- Department of anaesthesia and critical care, Amiens University Hospital, 80054 Amiens, France
| | - Emilien Arnaud
- Emergency department, Amiens University Hospital, 80054 Amiens, France
| | - Mathieu Guilbart
- Department of anaesthesia and critical care, Amiens University Hospital, 80054 Amiens, France
| | - Patricia Besserve
- Department of anaesthesia and critical care, Amiens University Hospital, 80054 Amiens, France
| | - Yazine Mahjoub
- Department of anaesthesia and critical care, Amiens University Hospital, 80054 Amiens, France.
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Affiliation(s)
- Sheila E Crowe
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA 92093-0063, USA
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26
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Affiliation(s)
| | | | | | - C Katona
- Helen Bamber Foundation, London, UK
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27
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McGilton KS, Vellani S, Babineau J, Bethell J, Bronskill SE, Burr E, Keatings M, McElhaney JE, McKay S, Nichol K, Omar A, Puts MTE, Singh A, Tamblyn Watts L, Wodchis WP, Sidani S. Understanding transitional care programmes for older adults who experience delayed discharge: a scoping review protocol. BMJ Open 2019; 9:e032149. [PMID: 31848166 PMCID: PMC6937058 DOI: 10.1136/bmjopen-2019-032149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Many hospitalised older adults experience delayed discharges due to increased postacute health and social support needs. Transitional care programmes (TCPs) provide short-term care to these patients to prepare them for transfer to nursing homes or back to the community with supports. There are knowledge gaps related to the development, implementation and evaluation of TCPs. The aims of this scoping review (ScR) are to identify the characteristics of older patients served by TCPs; criteria for transfer, components and services provided by TCPs; and outcomes used to evaluate TCPs. METHODS AND ANALYSIS The study involves six-step ScR and is informed by a collaborative/participatory approach whereby stakeholders engage in the development of the research questions, identification of literature, data abstraction and synthesis; and participation in consultation workshop. The search for scientific literature will be done in the Medline, PsychINFO, Emcare and CINAHL databases; as well, policies and reports that examined models of transitional care and the outcomes used to evaluate them will be reviewed. Records will be selected if they involve community dwelling older adults aged 65 years or older, or indigenous persons 45 years or older; and presented in English, French, Dutch and German languages. Records will be screened, reviewed and abstracted by two independent reviewers. Extracted data will be analysed using descriptive statistics and a narrative analysis, and organised according to Donabedian's model of structure (characteristics of older adults experiencing delayed discharge and served by TCPs), process (TCP components and services) and outcome. ETHICS AND DISSEMINATION This ScR does not require ethics approval. Dissemination activities include integrated knowledge translation (KT) (consultation with stakeholders throughout the study) and end-of-grant KT strategies (presentations at national and international conferences; and publication in peer-reviewed interdisciplinary journal).
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Affiliation(s)
- Katherine S McGilton
- Research, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Shirin Vellani
- Research, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Babineau
- Research, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | - Jennifer Bethell
- Research, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | - Susan E Bronskill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Elaine Burr
- North East Local Health Integration Network, Sudbury, Ontario, Canada
| | - Margaret Keatings
- Research, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | | | - Sandra McKay
- Visiting Homemakers Association Home Healthcare, Toronto, Ontario, Canada
| | - Kathryn Nichol
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Abeer Omar
- Research, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | - Martine T E Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Anita Singh
- Ontario Ministry of Health and Long-Term Care, Toronto, Ontario, Canada
| | - Laura Tamblyn Watts
- Policy and Research, Canadian Association of Retired Persons (CARP), Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Souraya Sidani
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada
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Affiliation(s)
- Michael Wilcock
- Department of Pharmacy, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - David Bearman
- Peninsula Academic Health Science Network, Exeter, UK
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Karlsson J, Eriksson T, Lindahl B, Fridh I. The Patient's Situation During Interhospital Intensive Care Unit-to-Unit Transfers: A Hermeneutical Observational Study. Qual Health Res 2019; 29:1687-1698. [PMID: 30810097 DOI: 10.1177/1049732319831664] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Interhospital intensive care unit-to-unit transfers are an increasing phenomenon, earlier mainly studied from a patient safety perspective. Using data from video recordings and participant observations, the aim was to explore and interpret the observed nature of the patient's situation during interhospital intensive care unit-to-unit transfers. Data collection from eight transfers resulted in over 7 hours of video material and field notes. Using a hermeneutical approach, three themes emerged: being visible and invisible; being in a constantly changing space; and being a fettered body in constant motion. The patient's situation can be viewed as an involuntary journey, one where the patient exists in a constantly changing space drifting in and out of the health personnel's attention and where movements from the journey become part of the patient's body. Interhospital transfers of vulnerable patients emerge as a complex task, challenging the health personnel's ability to maintain a caring atmosphere around these patients.
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Abstract
This case describes a design contest strategy to procure a solution to coordination of care transitions across healthcare programs to strengthen patient outcomes. The fit of the vendors' approach with the organization and the potential for building a strong relationship with the vendor teams were evaluated. A consortium of small Canadian companies was selected to proceed to a proof-of-concept phase and full implementation of the digital solution across the region. This design contest approach resulted in a successful vendor partnership for the organization to co-design, develop, implement and scale an innovative solution to support care transitions across the region.
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Affiliation(s)
- Anne W Snowdon
- Anne W. Snowdon, is a professor of strategy and entrepreneurship at the Odette School of Business, chair of the World Health Innovation Network and scientific director and CEO of SCAN Health (NCE), University of Windsor
| | - Ryan DeForge
- Ryan DeForge, is a senior researcher with the World Health Innovation Network, Odette School of Business, University of Windsor
| | - Renata Axler
- Renata Axler, is a senior researcher with the World Health Innovation Network, Odette School of Business, University of Windsor
| | - Melissa St Pierre
- Melissa St. Pierre, is a senior researcher with the World Health Innovation Network, Odette School of Business, University of Windsor
| | - Carol Kolga
- Carol Kolga, is a senior researcher with the World Health Innovation Network, Odette School of Business, University of Windsor
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Tijssen JA, Allen BN, Jenkyn KMB, Shariff SZ. Impact of Deferring Critically Ill Children Away from Their Designated Pediatric Critical Care Unit: A Population-Based Retrospective Cohort Study. Healthc Policy 2019; 15:40-52. [PMID: 31629455 PMCID: PMC7008691 DOI: 10.12927/hcpol.2019.25939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The impact of deferring critically ill children in referral hospitals away from their designated pediatric critical care unit (PCCU) on patients and the healthcare system is unknown. We aimed to identify factors associated with deferrals and patient outcomes and to study the impact of a referral policy implemented to balance PCCU bed capacity with regional needs. METHODS We conducted a population-based retrospective cohort study of admissions to a PCCU following inter-facility transport from 2004 to 2016 in Ontario, Canada. RESULTS Of 10,639 inter-facility transfers, 24.8% (95% confidence interval [CI]: 23.5-26.1%) were deferred during pre-implementation and 16.0% (95% CI: 15.1-16.9%) during post-implementation of a referral policy. Several factors, including previous intensive care unit admissions, residence location, presenting hospital factors, patient co-morbidities, specific designated PCCUs and winter (versus summer) season, were associated with deferral status. Deferrals were not associated with increased mortality. CONCLUSIONS Deferral from a designated PCCU does not confer an increased risk of death. Implementation of a referral policy was associated with a consistent referral pattern in 84% of transfers.
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Affiliation(s)
- Janice A Tijssen
- Children's Hospital, London Health Sciences Centre, Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON
| | - Britney N Allen
- Institute of Clinical Evaluative Sciences, Western Site (ICES Western), London, ON
| | - Krista M Bray Jenkyn
- Institute of Clinical Evaluative Sciences, Western Site (ICES Western), London, ON
| | - Salimah Z Shariff
- Institute of Clinical Evaluative Sciences, Western Site (ICES Western), Arthur Labatt School of Nursing, Western University, London, ON
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Abstract
The landscape of stroke systems of care is evolving as patients are increasingly transferred between hospitals for access to higher levels of care. This is driven by time-sensitive disability-reducing interventions such as mechanical thrombectomy. However, coordination and triage of patients for such treatment remain a challenge worldwide, particularly given complex eligibility criteria and varying time windows for treatment. Network analysis is an approach that may be applied to this problem. Hospital networks interlinked by patients moved from facility to facility can be studied using network modeling that respects the interdependent nature of the system. This allows understanding of the central hubs, the change of network structure over time, and the diffusion of innovations. This topical review introduces the basic principles of network science and provides an overview on the applications and potential interventions in stroke systems of care.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Boston
| | - Amar Dhand
- Department of Neurology, Brigham and Women's Hospital, Boston, MA (A.D.)
| | - Lee H Schwamm
- Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (J.-P.O.)
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Ramnarayan P, Evans R, Draper ES, Seaton SE, Wray J, Morris S, Pagel C. Differences in access to Emergency Paediatric Intensive Care and care during Transport (DEPICT): study protocol for a mixed methods study. BMJ Open 2019; 9:e028000. [PMID: 31315865 PMCID: PMC6661595 DOI: 10.1136/bmjopen-2018-028000] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Following centralisation of UK paediatric intensive care, specialist retrieval teams were established who travel to general hospitals to stabilise and transport sick children to regional paediatric intensive care units (PICUs). There is national variation among these PICU retrieval teams (PICRTs) in terms of how quickly they reach the patient's bedside and in the care provided during transport. The impact of these variations on clinical outcomes and the experience of stakeholders (patients, families and healthcare staff) is however unknown. The primary objective of this study is to address this evidence gap. METHODS AND ANALYSIS This mixed-methods project involves the following: (1) retrospective analysis of linked data from routine clinical audits (2014-2016) to assess the impact of service variations on 30-day mortality and other secondary clinical outcomes; (2) a prospective questionnaire study conducted at 24 PICUs and 9 associated PICRTs in England and Wales over a 12-month period in 2018 to collect experience data from parents of transported children as well as qualitative analysis of in-depth interviews with a purposive sample of patients, parents and staff to assess the impact of service variations on patient/family experience; (3) health economic evaluation analysing transport service costs (and other associated costs) against lives saved and longer term measurements of quality of life at 12 months in transported children and (4) mathematical modelling evaluating the costs and potential impact of different service configurations. A final work stream involves a series of stakeholder workshops to synthesise study findings and generate recommendations. ETHICS AND DISSEMINATION The study has been reviewed and approved by the Health Research Authority, ref: 2 18 569. Study results will be actively disseminated through peer-reviewed journals, conference presentations, social media, print and broadcast media, the internet and stakeholder workshops.
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Affiliation(s)
- Padmanabhan Ramnarayan
- Children’s Acute Transport Service, Great Ormond Street Hospital For Children NHS Trust, London, UK
| | - Ruth Evans
- Centre for Outcomes and Experience Research in Children’s Health, Illness and Disability (ORCHID), Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | | | - Sarah E Seaton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jo Wray
- Cardiorespiratory Division, Great Ormond Street Hospital for Children, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
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Klueh MP, Sloss KR, Dossett LA, Englesbe MJ, Waljee JF, Brummett CM, Lagisetty PA, Lee JS. Postoperative opioid prescribing is not my job: A qualitative analysis of care transitions. Surgery 2019; 166:744-751. [PMID: 31303324 DOI: 10.1016/j.surg.2019.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/08/2019] [Accepted: 05/29/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Persistent opioid use is common after surgical procedures, and postoperative opioid prescribing often transitions from surgeons to primary care physicians in the months after surgery. It is unknown how surgeons currently transition these patients or the preferred approach to successful coordination of care. This qualitative study aimed to describe transitions of care for postoperative opioid prescribing and identify barriers and facilitators of ideal transitions for potential intervention targets. METHODS We conducted a qualitative study of surgeons and primary care physicians at a large academic healthcare system using a semi-structured interview guide. Transcripts were independently coded using the Theoretical Domains Framework to identify underlying determinants of physician behaviors. We mapped dominant themes to the Behavior Change Wheel to propose potential interventions targeting these behaiors. RESULTS Physicians were interviewed between July 2017 and December 2017 beyond thematic saturation (n = 20). Surgeons report passive transitions to primary care physicians after ruling out surgical complications, and these patients often bounce back to the surgeon when primary care physicians are uncertain of the cause of ongoing pain. Ideal practices were identified as setting preoperative expectations and engaging in active transition for postoperative opioid prescribing. We identified 3 behavioral targets for multidisciplinary intervention: knowledge (guidelines for coordination of care), barriers (utilizing support staff for active transition), and professional role (incentive for multidisciplinary collaboration). CONCLUSION This qualitative study identifies potential interventions aimed at changing physician behaviors regarding transitions of care for postoperative opioid prescribing. Implementation of these interventions could improve coordination of care for patients with persistent postoperative opioid use.
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Affiliation(s)
- Michael P Klueh
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; University of Michigan Medical School, Ann Arbor, MI
| | - Kenneth R Sloss
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | | | - Michael J Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI.
| | - Jennifer F Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI; Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Pooja A Lagisetty
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jay S Lee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
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Farhat NM, Vordenberg SE, Marshall VD, Suh TT, Remington TL. Evolution of interdisciplinary geriatric transitions of care on readmission rates. Am J Manag Care 2019; 25:e219-e223. [PMID: 31318513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the effect of an interdisciplinary transitions of care (TOC) service on readmission rates in a geriatric population. STUDY DESIGN Single-center retrospective cohort study of adults 60 years or older discharged from an academic medical center. METHODS From July 1, 2013, to February 21, 2016, a total of 4626 patients discharged from 1 hospital, including inpatient, emergency department, observation, and short-stay units, were included. Cases were scheduled for a TOC service with the interdisciplinary team. Controls received usual care at other sites. All-cause 14-, 30-, and 90-day readmission rates between propensity score-matched study groups were evaluated by intention-to-treat (ITT), per-protocol (PP), and as-treated methods. RESULTS During the study period, 513 patients were scheduled for at least 1 component of the TOC intervention (ITT group). Of those patients, 215 completed all scheduled visits (PP group). Readmission rate after 30 days demonstrated no difference in the ITT group compared with the control group (12.8% vs 10.7%; P = .215), although it was significantly lower in the PP group in comparison with the control group (12.8% vs 7.9%; P = .042). CONCLUSIONS An interdisciplinary team based in a patient-centered medical home improved readmission rates for all patients who completed the intervention (PP group).
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Affiliation(s)
- Nada M Farhat
- Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202.
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Lauerman MH, Herrera AV, Albrecht JS, Chen HH, Bruns BR, Tesoriero RB, Scalea TM, Diaz JJ. Interhospital Transfers with Wide Variability in Emergency General Surgery. Am Surg 2019; 85:595-600. [PMID: 31267899 PMCID: PMC6995344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups: encounters not transferred, encounters transferred from a hospital, and encounters transferred to a hospital. In total, 380,405 EGS encounters were identified, including 12,153 (3.2%) encounters transferred to a hospital, 10,163 (2.7%) encounters transferred from a hospital, and 358,089 (94.1%) encounters not transferred. For individual hospitals, percentage of encounters transferred to a hospital ranged from 0 to 30.05 per cent, encounters transferred from a hospital from 0.02 to 14.62 per cent, and encounters not transferred from 69.25 to 99.95 per cent of total encounters at individual hospitals. Percentage of encounters transferred from individual hospitals was inversely correlated with annual EGS hospital volume (P < 0.001, r = -0.59), whereas percentage of encounters transferred to individual hospitals was directly correlated with annual EGS hospital volume (P < 0.001, r = 0.51). Individual hospital practices for interhospital transfer of EGS patients have substantial variability. This is the first study to describe individual hospital interhospital transfer practices for EGS.
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Giannini O, Rizza N, Pironi M, Parlato S, Waldispühl Suter B, Borella P, Pagnamenta A, Fishman L, Ceschi A. Prevalence, clinical relevance and predictive factors of medication discrepancies revealed by medication reconciliation at hospital admission: prospective study in a Swiss internal medicine ward. BMJ Open 2019; 9:e026259. [PMID: 31133583 PMCID: PMC6538074 DOI: 10.1136/bmjopen-2018-026259] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Medication reconciliation (MedRec) is a relevant safety procedure in medication management at transitions of care. The aim of this study was to evaluate the impact of MedRec, including a best possible medication history (BPMH) compared with a standard medication history in patients admitted to an internal medicine ward. DESIGN Prospective interventional study. Data were analysed using descriptive statistics followed by univariate and multivariate Poisson regression models and a zero-inflated Poisson regression model. SETTING Internal medicine ward in a secondary care hospital in Southern Switzerland. PARTICIPANTS The first 100 consecutive patients admitted in an internal medicine ward. PRIMARY AND SECONDARY OUTCOME MEASURES Medication discrepancies between the medication list obtained by the physician and that obtained by a pharmacist according to a systematic approach (BPMH) were collected, quantified and assessed by an expert panel that assigned a severity score. The same procedure was applied to discrepancies regarding allergies. Predicting factors for medication discrepancies were identified. RESULTS The median of medications per patient was 8 after standard medication history and 11 after BPMH. Total admission discrepancies were 524 (5.24 discrepancies per patient) with at least 1 discrepancy per patient. For 47 patients, at least one discrepancy was classified as clinically relevant. Discrepancies were classified as significant and serious in 19% and 2% of cases, respectively. Furthermore, 67% of the discrepancies were detected during the interview conducted by the pharmacist with the patients and/or their caregivers. The number of drugs used and the autonomous management of home therapy were associated with an increased number of clinically relevant discrepancies in a multivariable Poisson regression model. CONCLUSION Even in an advanced healthcare system, a standardised MedRec process including a BPMH represents an important strategy that may contribute to avoid a notable number of clinically relevant discrepancies and potential adverse drug events.
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Affiliation(s)
- Olivier Giannini
- Department of Internal Medicine, Ospedale Regionale di Mendrisio, Ente Ospedaliero Cantonale, Mendrisio, Ticino, Switzerland
| | - Nicole Rizza
- Hospital Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Michela Pironi
- Hospital Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Saida Parlato
- Hospital Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Paola Borella
- Department of Internal Medicine, Ospedale Regionale di Mendrisio, Ente Ospedaliero Cantonale, Mendrisio, Ticino, Switzerland
| | - Alberto Pagnamenta
- Unit of Clinical Epidemiology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Division of Pneumology, University of Geneva, Geneva, Switzerland
| | | | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
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Pervez MB, Hashmi S, Jabeen M, Fatimi SH. When surgeons are rarer than resources - our experience with improving access to thoracic surgery in an urban setting: A special report. J PAK MED ASSOC 2019; 69(Suppl 1):S77-S81. [PMID: 30697025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
With progressive globalisation enabled by technology, there is an increased interest in finding viable solutions to the myriad health problems faced by developing countries. In countries like Pakistan, occasionally the challenge is not a dearth of material resources but rather unavailability of expertise. The current paper was planned to share a model that was successfully implemented in the urban setting of Karachi, Pakistan, from 2012 onwards which significantly improved access to thoracic surgery for underprivileged individuals. Our model focussed on a qualified thoracic surgeon reviving a defunct thoracic surgical unit thereby optimising the use of resources already available in the community. The key to efficient outcomes was direct managerial control by the surgeon who first educated himself in the various processes involved. The model, with its challenges and solutions, has good potential foradaptation in other urban settings in the developing world..
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Affiliation(s)
- Mohammad Bin Pervez
- Section of Cardiothoracic Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Shiraz Hashmi
- Section of Cardiothoracic Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Mehnaz Jabeen
- Al Qassimi Women and Children's Hospital, Interhealth Canada Division, Sharjah, UAE
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Abstract
The ability to maintain functional status is an essential aspect of self-care for older adults. Instrumental activities of daily living (IADLs) decline within hours of hospitalization and are often overlooked, underassessed, and underreported. The aim of this integrative review was to examine and compare methods used to assess IADLs to determine the best measure for use across the care continuum, especially during transitions of care. A literature search without date restrictions was conducted using PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Embase databases. Twelve studies of moderate quality were included in this review. More than half (58%) of the studies utilized the Lawton and Brody Scale to measure IADL among home-based and hospitalized patients. Implementation of this scale as standard practice and sharing the results with healthcare providers would encourage continuity of care with the goal of supporting older adults aging in place and preventing rehospitalization. In turn, this communication process may improve the transition from the inpatient to home setting, where, since 1999, the Outcome and Assessment Information Set has been mandated.
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Affiliation(s)
- Irina Koyfman
- Irina Koyfman, MSN, RN, NP-C, is a Doctor of Nursing Practice Student, Johns Hopkins School of Nursing, Baltimore, Maryland. Deborah Finnell, DNS, CARN-AP, FAAN, is a Professor, Johns Hopkins School of Nursing, Baltimore, Maryland
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González García L, Márquez de Prado Yagüe M, Gargallo Burriel E, Ferrer Orona M, García García JJ, Alcalá Minagorre PJ. [Quality of clinical information management between hospital pediatric professionals]. J Healthc Qual Res 2019; 34:45-46. [PMID: 30391252 DOI: 10.1016/j.jhqr.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/21/2018] [Accepted: 08/27/2018] [Indexed: 06/08/2023]
Affiliation(s)
- L González García
- Servicio de Pediatría, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, España
| | - M Márquez de Prado Yagüe
- Servicio de Pediatría, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, España
| | - E Gargallo Burriel
- Servicio de Pediatría, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, España
| | - M Ferrer Orona
- Servicio de Pediatría, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, España
| | - J J García García
- Servicio de Pediatría, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, España
| | - P J Alcalá Minagorre
- Servicio de Pediatría, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, España.
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Wright T, Candy B, King M. Conversion therapies and access to transition-related healthcare in transgender people: a narrative systematic review. BMJ Open 2018; 8:e022425. [PMID: 30580262 PMCID: PMC6318517 DOI: 10.1136/bmjopen-2018-022425] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 08/16/2018] [Accepted: 10/18/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Conversion is a term for treatments that seek to suppress or change a person's sexual orientation or gender. Our review focuses on transgender and gender-diverse (TGD) people. Our aims were to (1) describe the frequency, nature and structure of conversion practices; (2) document difficulties in accessing transition-related healthcare and (3) evaluate the mental health consequences of such practices and access barriers. METHOD Systematic review and narrative synthesis using the Critical Appraisals Skills Programme and Joanne Briggs Institute critical appraisal tools. Data sources include Embase, MEDLINE, PsychINFO, PsychARTICLES and Web of Science between 1990 and June 2017. PARTICIPANTS Studies were included that (1) document use of conversion therapies or access barriers to transition-related healthcare; and/or (2) describe how such therapeutic practices and access barriers have been applied and/or (3) evaluate the mental health impacts of such therapies and difficulties accessing transition-related healthcare. Two reviewers screened papers for eligibility. Data were then grouped according to the objectives. Narratives and themes were presented per study. RESULTS Seven studies met inclusion criteria. Four reports were on 'realignment', involving case studies or case series. Two involved psychoanalysis, one self-exposure therapy and one open-ended play psychotherapy. All four studies concerning 'realignment' were of poor methodological quality. The other three studies explored access barriers from the view point of TGD youth, their parents and healthcare providers. All papers reported access barriers, such as inability to access puberty-delaying medications. The papers concerning barriers to access were of good methodological quality. CONCLUSION We found limited published evidence on use, nature, structure and/or health consequences of conversion therapies and access barriers to transition in TGD people. However, reports of restriction to access may indicate a more widespread problem. Research is needed into TGD people's experiences of conversion therapy and access barriers to transition-related healthcare TRIAL REGISTRATION NUMBER: CRD42017062149.
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Affiliation(s)
- Talen Wright
- Division of Psychiatry, University College London, London, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Michael King
- Division of Psychiatry, University College London, London, London, UK
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Norman S, DeCicco F, Sampson J, Fraser IM. Emergency Room Safer Transfer of Patients (ER-STOP): a quality improvement initiative at a community-based hospital to improve the safety of emergency room patient handovers. BMJ Open 2018; 8:e019553. [PMID: 30552238 PMCID: PMC6303585 DOI: 10.1136/bmjopen-2017-019553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Ensure early identification and timely management of patient deterioration as essential components of safe effective healthcare. Prompted by analyses of incident reports and deterioration events, a multicomponent organisational rescue from danger system was redesigned to decrease unexpected inpatient deterioration. DESIGN Quality improvement before-after unblinded trial. SETTING 430-bed Canadian community teaching hospital. PARTICIPANTS All admitted adult medical-surgical patients in a before-after 12-month interventional study. INTERVENTION Locally validated checklist (Modified Early Warning Score+urinary catheter in situ+nurse concern) with an intentional pause and explicit management options was deployed as a modification of an existing ward transfer of accountability fax report in the emergency department (ED). RESULTS Following deployment of Emergency Room Safer Transfer of Patients (ER-STOP), the risk of an unexpected CCRT (critical care response team) response within 24 hours of admission from ED to adult medical and surgical wards was significantly decreased (OR 4.1, 95% CI 2.17 to 7.77). Mean (±SD) ED wait times (5.66±1.54vs 5.74±1.04 hours, p=0.30), intensive care unit admission rate (3.84%, n=233vs 4.61%, n=278, p=0.06) and cardiac care unit admission rate (9.51%, n=577vs 9.60%, n=579, p=0.198) were unchanged. CONCLUSIONS ER-STOP improvement was out of proportion to the predictive value of the checklist component suggesting that effectiveness of this low-cost sustainable tool was related to increased situational awareness, empowering a culture of patient safety and repurposing of an adjacent ED medical short-stay unit use. Local adaptation within existing processes is essential to successful safety outcomes.
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Affiliation(s)
- Savannah Norman
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frank DeCicco
- Operational Excellence and Sustainability, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Jennifer Sampson
- Emergency Medicine, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Ian M Fraser
- Department of Medicine, Division of Respirology, University of Toronto and Michael Garron Hospital, Michael Garron Hospital, Toronto, Ontario, Canada
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Chioukh FZ, Ben Ameur K, Monastiri K, Kbaier H, Blibech S, Douagi M, Ben Hlel K, Ben Hamouda H, Soua H, Bouraoui A, Régaieg R, Gargouri A, Ksibi I, Kacem S, Mahdhaoui N, Ayech H, Sboui H. Transported neonates in Tunisia. Tunis Med 2018; 96:865-868. [PMID: 31131866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
AIMS To describe the transport of sick neonates to a tertiary care hospital and evaluate their condition at arrival and outcome. METHODS A multicenter, prospective cohort study was performed in 7 NICUs in Tunisia from 1st april to 31 July 2015.Demographic parameters, transport details and clinical features at arrival were recorded. All neonates were followed up till discharge or death. RESULTS A total of 239 consecutive neonates were enrolled in the study representing 5.7% of all admitted infants. Maternal risk factors were present in 26% of neonates admitted. Sex-ratio was 1.46. Preterm infants represented 24% of transported babies. Seventeen percent of neonates had severe respiratory distress and 10% had hemodynamic troubles. Referred hospital was not informed in 24% of cases. Regarding the transport mode, 113 newborns (47.5%) were transported in ambulance accompanied by a nurse. Documentation during transfert was present in 14% of cases. Five babies expired on arrival despite resuscitation. Rate mortality was 8.4%. CONCLUSION Transporting neonates in developing countries is a challenge. Organized transport services in Tunisia are not always available. So, in cases of at-risk pregnancy, it is safer to transport the mother prior to delivery than to transfer the sick baby after birth.
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Baxter R, O’Hara J, Murray J, Sheard L, Cracknell A, Foy R, Wright J, Lawton R. Partners at Care Transitions: exploring healthcare professionals' perspectives of excellence at care transitions for older people. BMJ Open 2018; 8:e022468. [PMID: 30232111 PMCID: PMC6150145 DOI: 10.1136/bmjopen-2018-022468] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/07/2018] [Accepted: 08/10/2018] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Hospital admissions are shorter than they were 10 years ago. Notwithstanding the benefits of this, patients often leave hospital requiring ongoing care. The transition period can therefore be risky, particularly for older people with complex health and social care needs. Previous research has predominantly focused on the errors and harms that occur during transitions of care. In contrast, this study adopts an asset-based approach to learn from factors that facilitate safe outcomes. It seeks to explore how staff within high-performing ('positively deviant') teams successfully support transitions from hospital to home for older people. METHODS AND ANALYSIS Six high-performing general practices and six hospital specialties that demonstrate exceptionally low or reducing 30-day emergency hospital readmission rates will be invited to participate in the study. Healthcare staff from these clinical teams will be recruited to take part in focus groups, individual interviews and/or observations of staff meetings. Data collection will explore the ways in which teams successfully deliver exceptionally safe transitional care and how they overcome the challenges faced in their everyday clinical work. Data will be thematically analysed using a pen portrait approach to identify the manifest (explicit) and latent (abstract) factors that facilitate success. ETHICS AND DISSEMINATION Ethical approval was obtained from the University of Leeds. The study will help develop our understanding of how multidisciplinary staff within different healthcare settings successfully support care transitions for older people. Findings will be disseminated to academic and clinical audiences through peer-reviewed articles, conferences and workshops. Findings will also inform the development of an intervention to improve the safety and experience of older people during transitions from hospital to home.
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Affiliation(s)
- Ruth Baxter
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Jane O’Hara
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
- Leeds Institute of Medical Education, University of Leeds, Leeds, West Yorkshire, UK
| | - Jenni Murray
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Laura Sheard
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Alison Cracknell
- Leeds Centre for Older People’s Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - John Wright
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Rebecca Lawton
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
- School of Psychology, University of Leeds, Leeds, UK
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Rosso CB, Saurin TA. The joint use of resilience engineering and lean production for work system design: A study in healthcare. Appl Ergon 2018; 71:45-56. [PMID: 29764613 DOI: 10.1016/j.apergo.2018.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 03/19/2018] [Accepted: 04/15/2018] [Indexed: 06/08/2023]
Abstract
Although lean production (LP) has been increasingly adopted in healthcare systems, its benefits often fall short of expectations. This might be partially due to the failure of lean to account for the complexity of healthcare. This paper discusses the joint use of principles of LP and resilience engineering (RE), which is an approach for system design inspired by complexity science. Thus, a framework for supporting the design of socio-technical systems, which combines insights from LP and RE, was developed and tested in a system involving a patient flow from an emergency department to an intensive care unit. Based on this empirical study, as well as on extant theory, eight design propositions that support the framework application were developed. Both the framework and its corresponding propositions can contribute to the design of socio-technical systems that are at the same time safe and efficient.
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Affiliation(s)
- Caroline Brum Rosso
- DEPROT/UFRGS (Industrial Engineering and Transportation Department, Federal University of Rio Grande do Sul), Av. Osvaldo Aranha, 99, 5. Andar, Porto Alegre, RS, CEP 90035-190, Brazil.
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Hoffman A, Fagan H, Casas-Melley A, Wei J, Hebra A. Hurricane Irma Impact on the Inpatient Population at a Tertiary Children's Hospital in Florida. Am Surg 2018; 84:1395-1400. [PMID: 30268164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Hurricane Irma resulted in the evacuation of 6.3 million people in Florida in September, 2017. Our tertiary Children's Hospital activated our incident command center (ICC) 24 hours before storm landfall, and preparations were made to accommodate vulnerable pediatric patients (VPP) or children with medical complexity. Our ICC was active for 92 hours and the hospital was staffed with 467 associates and 40 physicians. Urgent operative and interventional radiology procedures were performed during the storm. Thirteen patients were transferred to our facility and 13 VPP were sheltered. During the lockdown period, our facility operated at 90 per cent capacity inclusive of VPP. Personnel were used in critical areas in the hospital, independent of their base units. There were no adverse outcomes or complications. Timely activation of ICC and deployment of Team A 24 hours before storm hit allowed for safe hospital operations. Planning for the inflow of patients is imperative to allow for preemptive deployment of staff and resources for inpatients, transfers, emergency room admissions, and VPP. VPP should be monitored regionally as they will consume hospital resources during natural disasters and must be accounted for to allow for safe and effective care delivery for all patients.
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Shehab N, Greenwald JL, Budnitz DS. Anticoagulation Across Care Transitions: Identifying Minimum Data to Maximize Drug Safety. Jt Comm J Qual Patient Saf 2018; 44:627-629. [PMID: 30139564 DOI: 10.1016/j.jcjq.2018.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Triller D, Myrka A, Gassler J, Rudd K, Meek P, Kouides P, Burnett AE, Spyropoulos AC, Ansell J. Defining Minimum Necessary Anticoagulation-Related Communication at Discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition. Jt Comm J Qual Patient Saf 2018; 44:630-640. [PMID: 30064950 DOI: 10.1016/j.jcjq.2018.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 04/12/2018] [Accepted: 04/23/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Anticoagulated patients are particularly vulnerable to ADEs when they experience changes in medical acuity, pharmacotherapy, or care setting, and resources guiding care transitions are lacking. The New York State Anticoagulation Coalition convened a task force to develop a consensus list of requisite data elements (RDEs) that should accompany all anticoagulated patients undergoing care transitions. METHODS A multidisciplinary panel of 15 anticoagulation experts voluntarily completed an iterative Delphi process. Resources were disseminated and deliberated via remote technology, with consensus achieved via blinded electronic polling. RESULTS The panel reached consensus on a list of 15 RDEs for anticoagulation communication at discharge (the ACDC List). Consensus was rapidly achieved by the full panel on 13 elements, while 3 (2 of which were combined into 1 element) required multiple iterations and achieved consensus with votes from 8 available panelists. The elements encompassed a range of factors, including drug use and indications, previous exposure and duration of therapy, recent drug exposure and laboratory results and expectations for subsequent administration, therapy goals, patient education and comprehension, and expectations for clinical management. Twelve of the elements are applicable to any anticoagulant, and 3 are specific to warfarin. CONCLUSION The ACDC List identifies specific pieces of clinical information that a panel of anticoagulant experts agree should be communicated to downstream providers for all anticoagulated patients undergoing care transitions. Additional study is needed to objectively evaluate the ability of existing care systems to communicate the elements and to assess possible relationships between communication of the elements and clinical outcomes.
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Van Spall HGC, Lee SF, Xie F, Ko DT, Thabane L, Ibrahim Q, Mitoff PR, Heffernan M, Maingi M, Tjandrawidjaja MC, Zia MI, Panju M, Perez R, Simek KD, Porepa L, Graham ID, Haynes RB, Haughton D, Connolly SJ. Knowledge to action: Rationale and design of the Patient-Centered Care Transitions in Heart Failure (PACT-HF) stepped wedge cluster randomized trial. Am Heart J 2018; 199:75-82. [PMID: 29754670 DOI: 10.1016/j.ahj.2017.12.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 12/17/2017] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Heart Failure (HF) is a common cause of hospitalization in older adults. The transition from hospital to home is high-risk, and gaps in transitional care can increase the risk of re-hospitalization and death. Combining health care services supported by meta-analyses, we designed the PACT-HF transitional care model. METHODS Adopting an integrated Knowledge Translation (iKT) approach in which decision-makers and clinicians are partners in research, we implement and test the effectiveness of PACT-HF among patients hospitalized for HF. We use a pragmatic stepped wedge cluster randomized trial design to introduce the complex health service intervention to 10 large hospitals in a randomized sequence until all hospitals initiate the intervention. The goal is for all patients hospitalized with HF to receive self-care education, multidisciplinary care, and early follow-up with their health care providers; and in addition, for high-risk patients to receive post-discharge nurse-led home visits and outpatient care in Heart Function clinics. This requires integration of care across hospitals, home care agencies, and outpatient clinics in our publicly funded health care system. While hospitals are the unit of recruitment and analysis, patients (estimated sample size of 3200) are the unit of analysis. Primary outcomes are hierarchically ordered as time to composite all-cause readmissions / emergency department (ED) visits / death at 3 months and time to composite all-cause readmissions / ED visits at 30 days. In a nested study of 8 hospitals, we measure the patient-centered outcomes of Discharge Preparedness, Care Transitions Quality, and Quality Adjusted Life Years (QALY); and the 6-month health care resource use and costs. We obtain all clinical and cost outcomes via linkages to provincial administrative databases. CONCLUSIONS This protocol describes the implementation and testing of a transitional care model comprising health care services informed by high-level evidence. The study adopts an iKT and pragmatic approach, uses a robust study design, links clinical trial data with outcomes held in administrative databases, and includes patient-reported outcomes. Findings will have implications on clinical practice, health care policy, and Knowledge Translation (KT) research methodology.
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Affiliation(s)
- Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, Ontario; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario; Population Health Research Institute, Hamilton, Ontario.
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton, Ontario
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario
| | - Dennis T Ko
- Institute for Clinical Evaluative Sciences, Ontario; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario
| | - Quazi Ibrahim
- Population Health Research Institute, Hamilton, Ontario
| | - Peter R Mitoff
- Department of Medicine, University of Toronto, Toronto, Ontario; Department of Medicine, St. Joseph's Health Centre, Toronto
| | - Michael Heffernan
- Department of Medicine, Halton Health Care Services, Oakville, Ontario
| | - Manish Maingi
- Cardiac Health Program, Trillium Health Partners, Mississauga, Ontario
| | | | - Mohammad I Zia
- Department of Medicine, University of Toronto, Toronto, Ontario; Department of Medicine, Michael Garron Hospital, Toronto, Ontario
| | - Mohamed Panju
- Department of Medicine, McMaster University, Hamilton, Ontario
| | | | - Kim D Simek
- Population Health Research Institute, Hamilton, Ontario
| | - Liane Porepa
- Department of Medicine, Southlake Regional Health Centre, Newmarket, Ontario
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario
| | - R Brian Haynes
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario
| | - Dilys Haughton
- Hamilton Niagara Haldimand Brant Community Care Access Centre, Hamilton, Ontario
| | - Stuart J Connolly
- Department of Medicine, McMaster University, Hamilton, Ontario; Population Health Research Institute, Hamilton, Ontario
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