Care Of Complex Patients Research Articles

Interprofessional student hotspotting: preparing future health professionals to deliver team-based care for complex patients.

Interprofessional student hotspotting involves experiential and longitudinal learning about team-based care for patients with complex medical and social needs. As an emerging strategy for interprofessional education, there have been few research studies to examine student perspectives. This study used a descriptive qualitative approach to examine the experiences and perspectives of health professions students who participated in a six-month interprofessional student hotspotting program. At the end of the program, focus group interviews were conducted with 24 health professions students from medicine, social work, pharmacy, nursing, and health psychology. Thematic analysis revealed four themes: Observed benefits of interprofessional collaboration; Gained skills for collaborative care; Experienced difficulty managing group dynamics; and Learned approaches to caring for complex patients. The hotspotting program helped deepen students' appreciation for interprofessional team-based care. Repeated practice of teamwork skills during the six-month clinical learning experience resulted in students feeling more prepared to provide collaborative care for complex patients.

Pathophysiology and Treatment of Burns.

Management of burn patients in the prehospital and prolonged field care environments presents complex patient care and logistical challenges. The authors discuss the pathophysiology, diagnostics, longitudinal concerns, and treatment involved in the care of such patients.

A Project ECHO and Community Health Worker Intervention for Patients with Diabetes

BackgroundBoth community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes. We studied the effect of an intervention that combined these 2 approaches on glycemic control. MethodsPatients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same electronic health records databases to estimate the average treatment effect. ResultsAmong 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus postintervention periods (P < .001). As compared to the comparison group, the intervention was associated with a change in HbA1c of −0.2% (95% confidence interval [CI] −0.4%-0.5%) and −0.3 (95% CI −0.5–0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percentage of patients with HbA1c <8% in the late follow-up cohort (8.1%, 95% CI 2.2%−13.9%) but not the early follow-up cohort (3.6%, 95% CI −1.5% to 8.7%) DiscussionThe intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. Although combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed.

Noninvasive ventilation in children: A review for the pediatric anesthesiologist.

Preserving adequate respiratory function is essential in the perioperative period. Mechanical ventilation with endotracheal intubation is widely used for this purpose. In select patients, noninvasive ventilation (NIV) may be an alternative to invasive ventilation or may complement respiratory management. NIV is used to provide ventilatory support and increase gas exchange at the alveolar level without the use of an invasive artificial airway such as an endotracheal tube or tracheostomy. NIV includes both continuous positive airway pressure (CPAP) and noninvasive positive pressure ventilation. Indications for NIV range from acute hypoxic respiratory failure in the intensive care unit or the emergency department, to chronic respiratory failure in patients with neuromuscular disease with nocturnal hypoventilation. In the perioperative setting, NIV is commonly applied as CPAP, and bilevel positive airway pressure (BPAP). There are limited data on the role of NIV in children in the perioperative setting, and there are no clear guidelines regarding optimal timing of use and pressure settings of perioperative NIV. Contraindications to the use of NIV include reduced level of consciousness, apnea, severe respiratory distress, and inability to maintain upper airway patency or airway protective reflexes. Common problems encountered during NIV involve airway leaks and asynchrony with auto-triggering. High-flow nasal oxygen (HFNO) has emerged as an alternative to NIV when trying to decrease the work of breathing and improve oxygenation in children. HFNO delivers humidified and heated oxygen at rates between 2 and 70L/min using specific nasal cannulas, and flows are determined by the patient's weight and clinical needs. HFNO can be useful as a method for preoxygenation in infants and children by prolonging apnea time before desaturation, yet in children with decreased minute ventilation or apnea HFNO does not improve alveolar gas exchange. Clinicians experienced with these devices, such as pediatric intensivists and pulmonary medicine specialists, can be useful resources for the pediatric anesthesiologist caring for complex patients on NIV.

CCR5 and Biological Complexity: The Need for Data Integration and Educational Materials to Address Genetic/Biological Reductionism at the Interface of Ethical, Legal, and Social Implications.

In the age of genomics, public understanding of complex scientific knowledge is critical. To combat reductionistic views, it is necessary to generate and organize educational material and data that keep pace with advances in genomics. The view that CCR5 is solely the receptor for HIV gave rise to demand to remove the gene in patients to create host HIV resistance, underestimating the broader roles and complex genetic inheritance of CCR5. A program aimed at providing research projects to undergraduates, known as CODE, has been expanded to build educational material for genes such as CCR5 in a rapid approach, exposing students and trainees to large bioinformatics databases and previous experiments for broader data to challenge commitment to biological reductionism. Our students organize expression databases, query environmental responses, assess genetic factors, generate protein models/dynamics, and profile evolutionary insights into a protein such as CCR5. The knowledgebase generated in the initiative opens the door for public educational information and tools (molecular videos, 3D printed models, and handouts), classroom materials, and strategy for future genetic ideas that can be distributed in formal, semiformal, and informal educational environments. This work highlights that many factors are missing from the reductionist view of CCR5, including the role of missense variants or expression of CCR5 with neurological phenotypes and the role of CCR5 and the delta32 variant in complex critical care patients with sepsis. When connected to genomic stories in the news, these tools offer critically needed Ethical, Legal, and Social Implication (ELSI) education to combat biological reductionism.

Medical rehabilitation strategies in complex assistance of people with COVID-19. Literature review

Covid-19 infection is a challenge for the medical system. The development of programs and strategies for the rehabilitation of people in different stages of the disease is relevant and current. The study is a bibliographic synthesis that aimed to analyze the methods and strategies of medical rehabilitation of patients with the new “coronavirus infection”. Data were collected from the academic databases PubMed, PubMed Central, Google, collecting relevant articles from 2019-2021, using the keywords: [“Covid-19” or “Covid 19” or “2019- CoV” or “SARS- CoV” or“ new coronavirus” or “SARS-CoV-2”] and [“rehabilitation ”or“ physical medicine”]. Th e aim of the study was to estimate the consequences of COVID-19 and to identify methods of recovery treatment. Because Covid-19 severely affects the respiratory system, pulmonary rehabilitation interventions with respiratory techniques and postural drainage combined with other physiotherapeutic methods may be used for a patient with COVID-19. The wide range of clinical manifestations in COVID-19 reveals the importance of adapting the rehabilitation program to functional deficits and patient needs. Multifactorial programs combined with active and supportive methods (physical therapy, exercise, occupational therapy, reflex therapy) are effective and can be used in the complex care of patients with COVID-19 at all stages of treatment.

Nurse-to-Patient Ratios in Tele-Critical Care.

Nurse-to-Patient Ratios in Tele-Critical Care.

Workforce Development in Integrated Care: A Scoping Review.

Introduction:Integrated care aims to improve access, quality and continuity of services for ageing populations and people experiencing chronic conditions. However, the health and social care workforce is ill equipped to address complex patient care needs due to working and training in silos. This paper describes the extent and nature of the evidence on workforce development in integrated care to inform future research, policy and practice.Methods:A scoping review was conducted to map the key concepts and available evidence related to workforce development in integrated care.Results:Sixty-two published studies were included. Essential skills and competencies included enhancing workforce understanding across the health and social care systems, developing a deeper relationship with and empowering patients and their carers, understanding community needs, patient-centeredness, health promotion, disease prevention, interprofessional training and teamwork and being a role model. The paper also identified training models and barriers/challenges to workforce development in integrated care.Discussion and Conclusion:Good-quality research on workforce development in integrated care is scarce. The literature overwhelmingly recognises that integrated care training and workforce development is required, and emerging frameworks and competencies have been developed. More knowledge is needed to implement and evaluate these frameworks, including the broader health and social care workforces within a global context. Further research needs to focus on the most effective methods for implementing these competencies.

The Case for Interprofessional Teaching in Graduate Medical Education.

Interprofessional education has been promoted as a strategy to dismantle professional silos and promote collaborative patient care. Citing this, medical educators have emphasized the widespread integration of interprofessional education into undergraduate medical education curricula. However, in the current residency training environment, little reinforcement exists for principles gleaned from interprofessional education, and little is known about the role that interprofessional providers have in resident education. In this perspective, we offer the concept and practice of interprofessional teaching to bolster the benefits of interprofessional education during residency training. Interprofessional teaching, relatively unexplored and potentially underutilized, may offer many of the same benefits of interprofessional education but is more readily adapted for the graduate medical education setting. The intensive care unit, characterized by a culture of multidisciplinary teamwork and complex patient care, is an ideal setting in which to use interprofessional teaching. Prior to enthusiastically implementing interprofessional teaching interventions, careful consideration should be paid to the setting, strategies, and impact on all key stakeholders.

The effect of the Covid-19 pandemic on patient visits to the emergency department and hospitalizations in medical wards in an Israeli medical center

BackgroundThe Covid-19 pandemic began in Israel on February 2020. Between February and October 2020, 2 periods of lockdown were imposed on Israeli population.ObjectiveTo assess the effect of the Covid-19 pandemic on visits to the emergency department (ED) and on hospitalizations in medical wards in Israel’s Chaim Sheba Medical Center, and to compare the effect during the first and second lockdowns.MethodsData regarding the number of visits of non-Covid-19 patients to the ED and the number of admissions to the medical wards, were extracted from the computerized system of the hospital. Data were analyzed for patients' characteristics, length of stay in the medical wards, in hospital mortality and the rate of 7 and 30 days re-hospitalization, and compared to the same period during 2019.ResultsTotal visits to the Sheba ED during March-October decreased by 18.5%. The most dramatic decrease occurred during the first lockdown. The number of patients admitted to the Sheba medical wards decreased by 28% (P < 0.05). The length of stay decreased from 3.69 days during 2019 to 3.42 days during 2020 (P < 0.01). The most pronounced decrease in the length of stay was observed during the second month of the first lockdown. During the pandemic, hospitalized patients at Sheba were older and were less likely to be males. The in-hospital absolute non-COVID mortality decreased from 913 to 858 respectively.ConclusionsThe Covid-19 crisis emphasizes the role of medical wards in the care of complex patients. Medical wards in Israel were at the frontline of Israel's battle against this pandemic, while continuing to treat very complex non-Covid patients. To avoid burnout of the medical staff who treat very intensively complex patients, we believe these wards should be strengthen with specialists having expertise in treating these patients. Due to our insights, the Sheba medical Center is now redesigning the concept of how intensive care beds should be managed in a big tertiary center.

Secondary Interpretations of Diagnostic Imaging Examinations: Patient Liabilities and Out-of-Pocket Costs.

Secondary interpretations of diagnostic imaging examinations are increasingly performed to improve care for complex patients. We sought to determine associated patient-billed liabilities and out-of-pocket payments and to identify patient and imaging study characteristics that correlate with higher patient bills and out-of-pocket payments. Data extracted for 7,740 secondary imaging interpretations performed across our large metropolitan health system over 25 months included total professional charges, insurance payments, patient-billed liabilities, and patient out-of-pocket payments. Multivariable linear regression analyses were performed to identify patient and imaging factors associated with higher patient bills and out-of-pocket payments. Mean secondary interpretation professional charges, insurance payments, patient-billed liabilities, and patient out-of-pocket payments were $306.50, $108.02, $27.80, and $14.55, respectively. Patients received bills for 47.5% of services and made out-of-pocket payments for 17.1%. Patient-billed liabilities and out-of-pocket payments were higher for patients who were younger and uninsured and for secondary interpretations requested for patients seen in outpatient (versus inpatient) settings. Patient-billed liabilities and out-of-pocket payments were lower for patients who were Black (versus White) and had government-sponsored (versus commercial) insurance and for secondary interpretations performed during the second, third, or fourth (versus first) quarter of each calendar year. Observed differences between patient-billed liabilities and out-of-pocket payments suggest that secondary interpretations of diagnostic imaging examinations can result in small but real patient financial burdens. Improved price transparency and enhanced patient communication about the value of secondary interpretations could reduce potential surprises when patients receive these bills.

The Venerable Subclavian Line.

In this treatise, we will address one of the higher-risk procedures, subclavian vein cannulation, that a practitioner may undertake in the care of complex patients. All cardiothoracic surgeons and their trainees will need, on occasion, to put in central lines in a variety of circumstances, including in the operating room, in the intensive care unit, in emergency circumstances, and, occasionally, when other practitioners have been unsuccessful in their attempts to place a central line. We will describe, in detail, the anatomy of the subclavian vein, the preparation of the patient for subclavian vein cannulation, the infraclavicular approach to cannulation of the vein, and a few notes about the supraclavicular approach to the subclavian vein. It is self-evident that the priorities of central venous cannulation include safety of insertion, minimizing clot formation, and avoiding infection. We will dwell primarily on the principles of safe subclavian line insertion.

Strategies and results of oncofertility counseling in young breast cancer patients

Introduction. Breast cancer (BC) is the most common female neoplasm in Poland and worldwide, yet up to 7% of all cases is diagnosed &lt; 40 years of age. The increased BC morbidity rate in this age group as well as hope for late maternity need special attention. Material and methods. The data concerning the number of children and further procreation needs in women (n = 68), aged 18–40, diagnosed and treated for early breast cancer at the Greater Poland Cancer Center in 2018–2019, were taken from patients’ histories by an oncologist before (neo-)adjuvant systemic therapy. Results. Out of the 68 females surveyed, aged 18–40 (median age 36), 14 (21%) were childless at the moment of diagnosis. After being informed about the therapy, prognosis, side effects and oncofertility, 12 patients (18%) decided to have a consultation with a specialist in reproductive medicine; 5 of them (7%) already had children. In 2 women (3%), hormonal stimulation in combination with tamoxifen was used; then, oocytes were collected and cryopreserved. In 19 (28%), gonadotropine analogues were added to (neo-)adjuvant chemotherapy. In 17 patients (25%) pathogenic mutations in BRCA1/2 genes were found. Conclusions. Oncofertility counseling in young BC patients should be one of the fundamental elements of complex patient care.

Using positive deviance to improve timely access in primary care

BackgroundImproving timely access in primary care is a continued challenge in many countries. We used positive deviance to try and identify best practices for achieving timely access in our primary...

MP47-05 PHYSICIAN AND HOSPITAL MISALIGNMENT IN THE ERA OF WRVU: CAN THIS MODEL HURT THE CORE OF ACADEMIC MEDICINE?

You have accessJournal of UrologyPediatric Urology III (MP47)1 Sep 2021MP47-05 PHYSICIAN AND HOSPITAL MISALIGNMENT IN THE ERA OF WRVU: CAN THIS MODEL HURT THE CORE OF ACADEMIC MEDICINE? Patrick Curtin, Philip Latham, Hailey Silverii, and Shumyle Alam Patrick CurtinPatrick Curtin More articles by this author , Philip LathamPhilip Latham More articles by this author , Hailey SilveriiHailey Silverii More articles by this author , and Shumyle AlamShumyle Alam More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002068.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The work relative value unit or wRVU is an often controversial measurement of productivity used in many academic medical centers (AMC). The interests at AMCs including care of complex patients, resident education, and effective hospital utilization are not necessarily aligned with physician compensation. To test this hypothesis, we sought to determine the difference in wRVUs per minute of operative time before and after the development of our center for complex urologic reconstruction. METHODS: A retrospective review was performed for patients undergoing reconstructive urologic procedures using CPT codes. A second population of patients undergoing urologic procedures prior to the creation of our reconstructive urology center were identified for comparison. Hospital length of stay, operative time, and wRVUs generated were determined for both populations. RESULTS: 44 patients were identified who underwent reconstructive urologic procedures. For comparison, 29 operative days were identified during which a total of 50 patients had undergone a variety of general urologic surgeries during the same time frame in the prior year. An average of 84 wRVUs were per case for reconstructive surgery versus 34 wRVU per case for the general urology population (p<0.0001). The wRVU generated per minute of operative time was 0.176 vs 0.241 respectively (p=0.014). Average hospital length of stay was 11.6 days versus 2.4 days (p<0.0001). CONCLUSIONS: Complex cases exemplify the spirit of the AMC in many ways. Firstly, these surgeries serve at risk populations whose needs can not be addressed in the community hospital setting. Second, the operative and post operative periods allow for training of residents and staff. Lastly, they lead to increased utilization of hospital services helping to make the pediatric multidisciplinary team more financially viable. As demonstrated in the above analysis, non-reconstructive cases are more productive from a financial perspective for the physician, yet this stands contrary to the best interests of the hospital and AMC. The wRVU system, therefore, may create a disincentive for pediatric urologists performing complex reconstructive surgeries. Fewer complex cases performed a year may diminish quality outcomes. Additionally, decreasing exposure of trainees to this patient population negatively impacts education, leaving future generations less well prepared to treat complex disease processes. Source of Funding: Not applicable © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e824-e824 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patrick Curtin More articles by this author Philip Latham More articles by this author Hailey Silverii More articles by this author Shumyle Alam More articles by this author Expand All Advertisement Loading ...

The 10th anniversary of the world primary immunodeficiency week: A J Project celebration

The 10^th anniversary of the world primary immunodeficiency week: A J Project celebration

Creating Nursing Workplaces That Appropriately Manage Legal Risk

Nursing professionals constitute the largest occupational group in all healthcare system departments, and are the healthcare professionals who work most closely and frequently with patients. The complexity and variability of the human body make nursing a high-risk occupation. The practice behaviors of nursing professionals must be safe, competent, and ethical, and must comply with relevant laws and regulations. Based on statistics published by the Colorado Nurses Association and the Nurses Service Organization (2020), professional conduct (32.5%), scope of practice (2.8%), and documentation error or omission (9.7%) are the three most-common categories of litigation faced by nurse practitioners. Smart medicine, which has emerged in the past decade, poses potential risks to patient privacy, safety, and professional nursing-care standards and holds the potential to significantly transform or even revolutionize the legal industry (Neary & Chen, 2017). Therefore, legal risk management is of particular importance to the nursing profession. Creating a legal-risk-management program in a workplace may start by focusing on one or more workplace aspects (e.g., individuals, teams, organizations, systems). However, the most crucial element is the frontline implementer. Therefore, the beliefs and attitudes of nursing staff and hospital care attendants toward the legal risks that may arise from the process of patient care are critically related to whether these professionals adhere strictly to the code of practice (Fontaine et al., 2019). This column proposes a safety initiative (SAFE) for the nursing-care workplace through special articles such as "Legal Risk Management in Nursing Practice: The Importance of Duty of Care," "Legal Liability for Negligence: Nurse Aides Working in Hospitals," and "The Legal Risks Faced in Nursing and Smart Healthcare." This initiative entails familiarizing nursing staff and care attendants with the legal risks associated with the patient-care profession (Support); setting high standards for patient care in the workplace that address these risks (Arousing); giving positive feedback to strengthen personal motivation, technical operation, and interpersonal interactions (Feedback); and creating a healthy workplace for practitioners while carrying out complex patient care (Environment). Shakespeare's famous drama The Tempest includes the timeless saying: "what's past is prologue." Analyzing litigation cases provides critical evidence to guide the evolution and improvement of nursing workplaces. Learning from past experience enables nurses and hospital care attendants to help others in a safe and dignified manner that will benefit all people.

Effective Collaboration Towards Positive Perioperative Outcomes for the Cardiac Surgery Patient in the Preoperative Phase of Care

<h3>Background Information</h3> The pre-procedure clinic in our academic medical center provides preoperative evaluation and surgical preparation for patients. Nurses in the clinic care for complex patients and support multiple surgical specialties, including cardiac surgery. Workflows related to this subset of patients, specifically identification of blood type and antibodies, presented a particular challenge for the clinic and cardiac surgery patients were not always ready for the operating room (OR) on the day of surgery. There was a negative impact on on-time first case starts (OTFS), cardiac surgery staff utilization, and, most importantly, patient satisfaction when delays occurred the morning of surgery due to positive antibodies and the need for additional work up to prepare blood availability for surgery. <h3>Objectives of Project</h3> The project aims were to: 1) provide an efficient outpatient pre-operative 30-day blood band process in the pre-procedure evaluation clinic for the adult cardiac surgery patient as partners in care with the cardiac surgery service and 2) establish a mutually beneficial work flow between perioperative services and cardiac surgery staff to minimize downstream OR delays. <h3>Process of Implementation</h3> A consultative group guided perioperative services leadership to improve internal processes. Collaboration with the cardiac surgery clinic and patient administrative services staff was crucial for project success. The project team developed and implemented a cardiac surgery internal workflow for preoperative management and the team revised outpatient registration workflows. All patient care technicians in the pre-procedure evaluation clinic received education for preoperative 30-day blood band lab procurement and associated form storage. <h3>Statement of Successful Practice</h3> This poster illustrates that there had been an upward trend in meeting the divisional OTFS goal of ≥ 75%. As of 10/31/19, ≥ 80% of cardiac surgery first cases started on time as compared to only 55% of cases started on time in July 2019. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Perinanesthesia nurses can improve the care of their patients by employing performance innovation concepts to break down barriers to ensure multidisciplinary success. By engaging multiple perioperative disciplines, providers, and members of the patient care delivery team, both patient care and organizational goals can be met. The option of 30 day blood bands is expanding to other surgical services to avoid delays the morning of surgery.

Pediatric Intensive Care Unit (PICU) Patient Room Design: Identifying Safety Risks in Mirrored Rooms Through a Graphical Systems Analysis.

The objectives of this study are to graphically depict specific clinical challenges encountered in a mirrored pediatric intensive care unit patient room and to represent potential solutions to address these challenges using a systems approach. The intensive care unit (ICU) patient room is a highly complex patient care environment where the design of the room must support patient care delivery safely and efficiently. There is a lack of research examining how ICU design elements interact with other system components to impact patient care. An observational case study method utilizing a systems approach was used to observe and graphically depict clinical challenges with mirrored room configurations and to identify potential solutions. Video recordings of the three clinical scenarios were analyzed in detail in conjunction with three rounds of interviews with a clinical expert. Equipment or task characteristics that require orienting to a specific side of a patient create challenges in a mirrored room. In order to deliver care safely and efficiently in the mirrored room, adaptations would be required including changing boom, equipment and team member locations, purchasing new equipment, staff training, and inventory management. Some procedures such as extracorporeal membrane oxygenation would be difficult to conduct safely in the mirrored room, even with significant adaptations. Solutions to the challenges presented in mirrored room configurations are multifaceted and require simultaneous and ongoing changes to multiple systems elements, while others can be addressed relatively easily, for example, purchasing new equipment.

A Community Partnership to House and Care for Complex Patients

Summary Rising homelessness, especially among older adults, has significant ramifications for our health care system. People experiencing homelessness tend to experience worse health and poorer access to needed health care than do people with stable housing. Commonwealth Care Alliance (CCA), a not-for-profit payer and provider that offers health plans to people dually eligible for Medicare and Medicaid, sought to address homelessness among its beneficiaries through a partnership with a local community-based housing organization, Hearth. This partnership led to many CCA beneficiaries gaining access to permanent supportive housing in a setting that allowed CCA and Hearth to monitor and address their medical, social, and behavioral needs. It also provided an opportunity to examine health care utilization and cost trends associated with permanent supportive housing. The authors' experience demonstrates that a community-based partnership can effectively address homelessness among older adults with significant medical needs and that permanent supportive housing may contribute to meaningful reductions in health care expenditures.