Complex Health Care System Research Articles

A mixed-methods needs assessment of traumatic brain injury care in a low- and middle-income country setting: building neurocritical care capacity at two major hospitals in Cambodia.

The high global burden of traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). These settings also have the greatest disparity in the availability of surgical care in general and neurosurgical care in particular. Recent focus has been placed on alleviating this surgical disparity. However, most capacity assessments are purely quantitative, and few focus on concomitantly assessing the complex healthcare system needs required to care for these patients. The objective of the present study was to use both quantitative and qualitative assessment data to establish a comprehensive approach to inform capacity-development initiatives for TBI care at two hospitals in an LMIC, Cambodia. This mixed-methods study used 3 quantitative assessment tools: the World Health Organization Personnel, Infrastructure, Procedures, Equipment, Supplies (WHO PIPES) checklist, the neurosurgery-specific PIPES (NeuroPIPES) checklist, and the Neurocritical Care (NCC) checklist at two hospitals in Phnom Penh, Cambodia. Descriptive statistics were obtained for quantitative results. Qualitative semistructured interviews of physicians, nurses, and healthcare administrators were conducted by a single interviewer. Responses were analyzed using a thematic content analysis approach and coded to allow categorization under the PIPES framework. Of 35 healthcare providers approached, 29 (82.9%) participated in the surveys, including 19 physicians (65.5%) and 10 nurses (34.5%). The majority had fewer than 5 years of experience (51.7%), were male (n = 26, 89.7%), and were younger than 40 years of age (n = 25, 86.2%). For both hospitals, WHO PIPES scores were lowest in the equipment category. However, using the NCC checklist, both hospitals scored higher in equipment (81.2% and 62.7%) and infrastructure (78.6% and 69.6%; hospital 1 and 2, respectively) categories and lowest in the training/continuing education category (41.7% and 33.3%, hospital 1 and 2, respectively). Using the PIPES framework, analysis of the qualitative data obtained from interviews revealed a need for continuing educational initiatives for staff, increased surgical and critical care supplies and equipment, and infrastructure development. The analysis further elucidated barriers to care, such as challenges with time availability for experienced providers to educate incoming healthcare professionals, issues surrounding prehospital care, maintenance of donated supplies, and patient poverty. This mixed-methods study identified areas in supplies, equipment, and educational/training initiatives as areas for capacity development for TBI care in an LMIC such as Cambodia. This first application of the NCC checklist in an LMIC setting demonstrated limitations in its use in this setting. Concomitant qualitative assessments provided insight into barriers otherwise undetected in quantitative assessments.

The Need for Objective and Remote Tracking of Chronic Skin Diseases

Importance: Managing chronic skin disease is often frustrating for both providers and patients, sometimes resulting in delayed diagnosis, inadequate therapy, and inconsistent care.Objective: This study performs stakeholder analyses to identify unmet clinical needs in chronic skin disease management. Methods: Survey of 33 providers and 25 patients at a Stanford Health Care Dermatology department.Results: When evaluating a chronic skin condition such as psoriasis, 79% of dermatologists rely solely on subjective documentation (gestalt, body surface area, descriptive exam). Objective documentation (photographs or scoring assessment tools) is used by 21% of providers upon initial assessment and by 7% of providers to assess change in disease between office visits. While 83% of providers were comfortable assessing change in disease severity based on prior document by oneself, only 31% were comfortable assessing change based on prior documentation by another provider (p <0.001). Dermatologists expressed the need for better documentation modality in clinic (94%), and in between office visits by patients (91%). While 90% of patients reported it is moderately to extremely important to track their disease, only 16% of patients consistently do. Most patients preferred to monitor their disease at home (92%) using cameras (80%) or by smartphone (59%). Patients were willing to spend 5-30 minutes weekly to monthly to document their disease.Conclusions and Relevance: This study identifies that dermatologists and patients need a solution that objectively and remotely monitors chronic skin diseases to optimize treatments, empower patients, and provide more cohesive care in a complex healthcare system.

An intern’s case study analysis of the patient transport function

Study provides an understanding of a hospital’s patient transportation department (PTD) and its essential function within a complex health care system. A participant-observer case study was accomplished using an intern’s extended exposure to first-hand interactions with managers, directors, and employees. The narrative delineates the importance of patient transportation in a large, expanding, fast-paced integrated delivery system; an environment requiring daily vigilance, continuous improvement, strategic positioning, innovation, and anticipation of future service needs. The departmental challenges and benefits of a facility-wide transition to a new electronic health information system are specified. The intern’s insights into the strategies and data sources that leadership uses to ensure departmental operating effectiveness are identified. Future PTD operations research opportunities are summarized.

Application of machine learning methodology to assess the performance of DIABETIMSS program for patients with type 2 diabetes in family medicine clinics in Mexico

BackgroundThe study aimed to assess the performance of a multidisciplinary-team diabetes care program called DIABETIMSS on glycemic control of type 2 diabetes (T2D) patients, by using available observational patient data and machine-learning-based targeted learning methods.MethodsWe analyzed electronic health records and laboratory databases from the year 2012 to 2016 of T2D patients from six family medicine clinics (FMCs) delivering the DIABETIMSS program, and five FMCs providing routine care. All FMCs belong to the Mexican Institute of Social Security and are in Mexico City and the State of Mexico. The primary outcome was glycemic control. The study covariates included: patient sex, age, anthropometric data, history of glycemic control, diabetic complications and comorbidity. We measured the effects of DIABETIMSS program through 1) simple unadjusted mean differences; 2) adjusted via standard logistic regression and 3) adjusted via targeted machine learning. We treated the data as a serial cross-sectional study, conducted a standard principal components analysis to explore the distribution of covariates among clinics, and performed regression tree on data transformed to use the prediction model to identify patient sub-groups in whom the program was most successful. To explore the robustness of the machine learning approaches, we conducted a set of simulations and the sensitivity analysis with process-of-care indicators as possible confounders.ResultsThe study included 78,894 T2D patients, from which 37,767patients received care through DIABETIMSS. The impact of DIABETIMSS ranged, among clinics, from 2 to 8% improvement in glycemic control, with an overall (pooled) estimate of 5% improvement. T2D patients with fewer complications have more significant benefit from DIABETIMSS than those with more complications. At the FMC’s delivering the conventional model the predicted impacts were like what was observed empirically in the DIABETIMSS clinics. The sensitivity analysis did not change the overall estimate average across clinics.ConclusionsDIABETIMSS program had a small, but significant increase in glycemic control. The use of machine learning methods yields both population-level effects and pinpoints the sub-groups of patients the program benefits the most. These methods exploit the potential of routine observational patient data within complex healthcare systems to inform decision-makers.

PROBLEM SOLVING SKILLS AND CANCER SCREENING BEHAVIORS IN MIDDLE-AGED AND OLDER MEN IN THE U.S.

Routine cancer screening is widely recognized as an effective strategy for reducing cancer mortality – the second leading cause of death in the U.S. Research shows cancer screening rates need to be improved, and men are less likely to uptake recommended screening than women. Cancer screening requires an array of tasks such as seeking up-to-date guidelines, making appointments, planning a hospital visit, and communicating with health care professionals in the complex health care systems. Importantly, modern health care systems are rapidly adopting technology such as web-based applications for information dissemination and communication with patients. This current study is designed to better understand the roles of problem-solving skills in the technology-rich environment (PSTRE) in two selected cancer screening behaviors among middle-aged and older men. We obtained nationally representative data with a sophisticated PSTRE assessment from the 2012/2014 Program for the International Assessment of Adult Competencies (PIAAC). Binary logistic regression models with survey weights were used to estimate the association between PSTRE scores (1 – 500 points) and two cancer screening behaviors of men who meet the recommended guideline of age between 45 to 74 years old (n = 1,168). Results showed that greater PSTRE scores were positively associated with prostate cancer screening (OR = 1.005, p < 0.05). Improvement in PSTRE may promote the specific cancer screening behaviors. Our findings also inform future interventions that seek to improve cancer screening among a vulnerable section of older populations.

A call to action: Building evidence for use of simulation in nurse practitioner education.

Leaders from national nursing organizations, nursing schools, and health care simulation vendors convened in early 2019 to discuss simulation in nurse practitioner (NP) education. Nurse practitioner clinical education needs a more standardized, efficient, and sustainable model to prepare NPs to provide quality care in complex health care systems. Currently, a major shortage of clinical sites and preceptors to educate students creates challenges for NP programs and nursing faculty. One strategy used by nursing programs to overcome this challenge is using simulation to provide clinical training for NP students in a safe, controlled environment. There remains, however, a lack of evidence linking these simulation experiences with clinical skills acquisition and program outcomes. Implementing competency-based education through standardized simulations has the potential to demonstrate quality, safety, and accountability across NP education programs. Ultimately, the expansion and acceptance of simulation hours in NP education is dependent on strong and favorable evidence from rigorous, high-quality studies.

Team-based learning (TBL): a community of practice

BackgroundRapid changes in medical practice have a large impact on the demands faced by educators in preparing students for future participation in a multifaceted healthcare workforce. Competencies required by today’s medical graduates encompass the ability to effectively collaborate, communicate and problem solve. The learning needs of medical students have also changed over time. Today’s medical students are highly interconnected, enjoying teamwork and collaborative practice, and desire continuous, explicit feedback. They want structured learning activities, with clear expectations, and enjoy a sense of accomplishment on their achievements. The conflation of these issues has seen many medical schools adopt the model of Team-based learning (TBL). Using the conceptual framework of communities of practice, we sought to qualitatively explore students’ and teachers’ experience of TBL in Year 1 of a graduate entry medical program.MethodsConvenience sampling was used to select 169/350 (48%) Year 1 students who completed three TBL sessions. Each TBL session was facilitated by three senior clinicians. Following participation in the TBLs, students were invited to attend focus groups, and all facilitators (n = 9) were invited to attend interviews. A coding framework was developed to code the entire dataset, using the theoretical lens of communities of practice.Results34/169 (20%) of students attended focus groups. Three facilitators (3/9, 33%) were interviewed. Students and facilitators felt the structure and organisation of TBL made students accountable for their learning and team contributions. The combined expertise and clinical experience of facilitators, with immediate feedback helped groups to work both independently and collaboratively. Facilitators found working with their peers in the TBLs to be a rewarding experience.ConclusionsThe community of practice found in the TBL classes, provided an enriching and rewarding learning environment that motivated students to build on their basic knowledge and apply what had been learnt. The interactions of experienced, senior clinicians as facilitators, sharing their expertise within a clinical context, prompted effective student engagement in learning and understanding. Our change in curriculum design and pedagogy will assist in preparing medical students for demands of the increasingly complex healthcare systems in which they will work.

Adaptive behavior of clinicians in response to an over-constrained patient safety policy on the administration of concentrated potassium chloride solutions

In response to fatal accidents involving concentrated potassium chloride (KCl) solutions, the Japanese hospital accreditation body released a safety policy in 2004 requiring the use of foolproof diluted KCl solutions throughout hospitals. However, the policy caused difficulties in treating seriously ill patients in critical care settings who require concentrated KCl solutions promptly. Resilient health care (RHC) provides a theoretical perspective for understanding how work is achieved in complex healthcare systems. ‘Work-as-imagined’ (WAI), as it should be done, and ‘work-as-done’ (WAD), as it actually takes place, are core concepts for understanding performance adjustment among individuals. This study aimed to investigate WAD regarding the administration of KCl solutions in the environment changed by WAI according to the authoritative policy.In 2017, we sent questionnaires to 346 critical care physicians. Topics included types of KCl products available in their units, administration methods, need for concentrated KCl solutions, hospital policies, and physician opinions. The response rate was 30.3% (105/346). Thirty-five physicians (33.3%) used conventional products out of compliance with the safety policy. Among 95 physicians using foolproof products, 69 (72.6%) obtained concentrated solutions from the products in an unsafe manner. The gap between WAI and WAD necessitated performance adjustments by physicians that introduced a new risk of adverse events despite the use of safer products.The study demonstrated that RHC theory can be used to inform the development and improvement of patient safety policies. Policy makers need to understand WAD when intervening in complex adaptive systems such as health care.

Servant Leadership in the Veterans Health Administration

The Veterans Health Administration (VHA) has determined that servant leader characteristics are desirable and have chosen servant leadership as their leadership model. Servant leadership is alive and well within the largest health care system in the United States, and this model has been a guiding force for many nurse leaders to survive and thrive in a challenging, complex, and transparent health care system. The Veterans Health Administration (VHA) has determined that servant leader characteristics are desirable and have chosen servant leadership as their leadership model. Servant leadership is alive and well within the largest health care system in the United States, and this model has been a guiding force for many nurse leaders to survive and thrive in a challenging, complex, and transparent health care system. Ruth W. Mustard, MSN, RN, NEA-BC, is Associate Director, Patient Care/Nursing Services, at the Columbia VA Health Care System in Columbia, South Carolina. She can be reached at [email protected]

An Evaluation of System End-User Support during Implementation of an Electronic Health Record Using the Model for Improvement Framework.

Electronic health record (EHR) system implementation is complex. Strong support for clinicians and other end-users during the initial phase of implementation requires dedicated resources and commitment to ensure a smooth transition, reduce frustration, and assist in adoption. Evaluate end-user support processes and personnel employed during the initial phase of EHR implementation at an academic medical center and identify facilitators of success, challenges, and lessons learned. Using the model for improvement framework, this case report describes the activities that follow the concepts of planning, doing, studying, and acting (PDSA) when providing on-site support to system end users during an EHR implementation in a complex health care system. Strengths included engaged and supportive leadership, use of internal support personnel, use of zone leaders, daily huddles for effective dissemination of information, and an evaluation survey tool to provide data supporting rapid changes in support personnel allocation. Challenges primarily surrounded the management of over 1,000 external support personnel which included limited EHR system knowledge, scheduling, and transportation logistics. Implementation of EHR systems continues. Supporting end users is one aspect of these complex projects that require dedicated resources to manage effectively. Organizations taking a more proactive approach, based on learning from experiences, as well as from other health care organizations, can improve their ability to take on this challenge armed with best practices and lessons learned.

198 The Next Steps: The Development of Dementia Post-diagnostic Psychoeducational Support Guidance

Abstract Background There is often a `care gap' where people are given a clinical diagnosis of dementia but receive no useful support. (Foley, T. et al., 2019) However, the early stages of dementia are a crucial time for supportive interventions such as advice and strategies to cope with impairments and improve wellbeing and signposting through complex healthcare systems to access key supports and services. In February 2018 the National Dementia Office (NDO) commissioned the Dementia Services Information and Development Centre (DSIDC) to develop a guidance document to support health and social care professionals (HSCPs) establish, organise and facilitate evidence-based post-diagnostic pyschoeducatonal interventions in the community. Methods The DSIDC undertook an extensive literature review examining the evidence for multi-component psychoeducational interventions. An experienced group of health and social care professionals provided additional material and expertise resulting in the development of the final guidance document. Members of the Irish Working Group of People with Dementia and the Dementia Carers Campaign Network also reviewed the document. Results The literature review found a growing evidence base for dyadic interventions. These interventions, directed at the person with dementia and their care partner, were diverse in their content, outcomes, the measures they used, their frequency and the professional background of the facilitators. They were flexible and cost-effective and drew on the HSCP's own professional knowledge, service resources and experiences of what works and what doesn't. Conclusion Dyadic interventions (and psychoeducational programmes in particular) have the potential to benefit both people with dementia and their care partners by decreasing depression and anxiety, increasing knowledge and coping skills and helping improve cognitive function. (Moon and Betts Adams, 2012) The practical guidance document developed from this review provides HSCPs with useful advice and information to facilitate the setting up and running of post-diagnostic psychoeducational support programmes.

How older people enact care involvement during transition from hospital to home: A systematic review and model.

BackgroundCurrent models of patient‐enacted involvement do not capture the nuanced dynamic and interactional nature of involvement in care. This is important for the development of flexible interventions that can support patients to ‘reach‐in’ to complex health‐care systems.ObjectiveTo develop a dynamic and interactional model of patient‐enacted involvement in care.Search strategyElectronic search strategy run in five databases and adapted to run in an Internet search engine supplemented with searching of reference lists and forward citations.Inclusion criteriaQualitative empirical published reports of older people's experiences of care transitions from hospital to home.Data extraction and synthesisReported findings meeting our definition of involvement in care initially coded into an existing framework. Progression from deductive to inductive coding leads to the development of a new framework and thereafter a model representing changing states of involvement.Main resultsPatients and caregivers occupy and move through multiple states of involvement in response to perceived interactions with health‐care professionals as they attempt to resolve health‐ and well‐being‐related goals. ‘Non‐involvement’, ‘information‐acting’, ‘challenging and chasing’ and ‘autonomous‐acting’ were the main states of involvement. Feeling uninvolved as a consequence of perceived exclusion leads patients to act autonomously, creating the potential to cause harm.Discussion and conclusionThe model suggests that involvement is highly challenging for older people during care transitions. Going forward, interventions which seek to support patient involvement should attempt to address the dynamic states of involvement and their mediating factors.

A Vision for Excellence by Design.

Generating evidence for care improvement has characterized my program of research spanning 20 years. Six domains are highlighted to advance the science and practice of critical care nursing in today's complex health care systems. Employee well-being and taking care of team members are key priorities for successful leaders. Understanding that patient and staff outcomes are inextricably linked strengthens the need for care environments to be healing and holistic for staff and patients. The American Association of Critical-Care Nurses' Healthy Work Environment framework empowers staff and optimizes the experience for patients, their families, and care teams. Appropriate staffing, guided by contemporary acuity measurement, takes into account the cognitive workload and complexity of nursing. Committing to a culture of certification and ensuring staffing models with appropriately educated and experienced nursing staff will remain important. In the past decade, we have established the impact of these specific nursing characteristics on improved patient outcomes. Understanding the attributes of empathic and empowered teams is requisite for authentic leadership. Interventions to mitigate moral distress are necessary to foster moral resilience among critical care nurses. The challenge for the future will be to support organizational health through the coexistence of highly reliable processes and clinical innovation. Excellence is achieved when systems are designed to support professional practice and clinical teams and environments.

A Historical View on Health Care: A New View on Austerity?

It is an axiom of contemporary conversations about austerity and health care that the relationship between the two is essentially direct. Cutting funds damages health care systems and hurts the health of individuals who rely on them. Though this premise has provoked necessary discussion about global politics, the global economy and their impact on individual well-being, it is nonetheless intrinsically problematic. Assigning health and health care as objects of austerity not only obscures the complexity of health care systems and the opacity of health’s definitional borders, but also misunderstands austerity, its manifestations and its significance. The ambition of this essay is to bring health care back into the debate, in order to establish the greater dynamism of the contemporary austerity and health care relationship. This historical reconstruction will challenge the significance of our current situating of austerity as health care’s bogeyman, press for a reconsideration of our contemporary definitions of the key factors involved here (health, health care and austerity) and finally conclude with some thoughts on how we might more productively approach the problem of health now.

Health seeking behavior among individuals presenting with chronic cough at referral hospitals in Uganda; Missed opportunity for early tuberculosis diagnosis.

BackgroundTuberculosis (TB) is the 9th leading cause of death from a single infectious agent. Patients live in a complex health care system with both formal and informal providers, and it is important that a TB diagnosis is not missed at the first interaction with the health care system. In this study, we highlight the health seeking behavior of patients and missed opportunities for early TB diagnosis for which interventions could be instituted to ensure early TB diagnosis and prompt TB treatment initiation.MethodsThis study was nested in a cross-sectional study that assessed the accuracy of different Xpert MTB/Rif implementation strategies in programmatic settings at the referral hospitals in Uganda. We documented the symptom profile of presumptive TB patients and assessed the health seeking behavior of those with chronic cough by calculating proportion of patients that visited each type of health facility and further calculated the odds of being TB positive given the type of health facility initially visited for consultation.ResultsA total of 1,863 presumptive TB patients were enrolled of which 979 (54.5%) were male, and 1795 (99.9%) had chronic cough. A total of 1352 (75.4%) had previously sought care for chronic cough, with 805 (59.6%) seeking care from a public health facility followed by private health facility (289; 21.4%). Up to 182 (13.5%) patients visited a drug store for chronic cough. Patients whose first contact was a private health facility were more likely to have a positive GeneXpert test (adjOR 1.4, 95% CI: 1.0–1.9; p = 0.047).ConclusionsChronic cough is a main symptom for many of the presumptive TB patients presenting at referral hospitals, with several patients having to visit the health system more than once before a TB diagnosis is made. This suggests the need for patients to be thoroughly evaluated at first interface with the health care system to ensure prompt diagnosis and treatment initiation. Improved TB diagnosis possibly with the GeneXpert test, at first contact with the health care system has potential to increase TB case finding and break the transmission cycle in the community.

Exploring The Views Of Stroke Survivors Around Post Stroke Fatigue In Saudi Arabia: A Qualitative Interview Study

Background/Aims Among stroke survivors, post-stroke fatigue is highly prevalent, ranging from 25% to 85% and has a significant impact on their quality of life. The available literature on post-stroke fatigue is still rudimentary, especially from middle-eastern countries such as Saudi Arabia, which is a country with a complex health care system and diverse population. The aim of this study is to explore the post-stroke survivors' experiences and perceptions of their post-stroke fatigue. To our knowledge, this is the first attempt to understand post-stroke fatigue among stroke survivors living in Saudi Arabia. Methods This was a qualitative study where semi-structured interviews were conducted with stroke survivors who were diagnosed to have fatigue based on the Fatigue Severity Scale. A total of eight participants were recruited using a purposive sampling technique for the study. Interviews with the participants were recorded, transcribed verbatim and analysed using inductive thematic analysis. Validity was ensured through data triangulation with participants. Results The 8 participants (male=4; female=4), aged between 27 and 65 years (mean 52, standard deviation 14), were interviewed. Their scores on the Fatigue Severity Scale ranged from 4.5 to 6 (mean 5.3, standard deviation 0.5). On analysing the interview transcripts, 8 over-arching themes were generated: fatigue after stroke; symptomatology of post-stroke fatigue; pre-stroke fatigue levels and lifestyle; stroke survivors' perspectives of post-stroke fatigue; post-stroke fatigue's impact on daily living; coping with post-stroke fatigue; post-stroke fatigue patients' perception on physiotherapy; type of support from family and health care professional. Conclusions The results from this study highlights the lack of awareness about fatigue after stroke among stroke survivors. Also, the themes indicate that there is a need to educate stroke patients and their caregivers about post-stroke fatigue and how they should manage it. Based on patients ‘experiences’, physiotherapy seems to be helpful in reducing fatigue symptoms after stroke, but sill there is a need to design specific physiotherapy interventions with suitable frequency and intensity to target fatigue after stroke. In summary, post-stroke fatigue has a significant impact on their quality of life concerning social participation and their daily life. Stroke survivors did not receive enough support from health care professionals with respect to post-stroke fatigue, and it is highly essential to train health care practitioners to identify and acknowledge post-stroke fatigue appropriately.

Exploring nursing competence to care for older patients in municipal in-patient acute care: A qualitative study.

To identify critical aspects of nursing competence to care for older patients in the context of municipal in-patient acute care. An increasingly complex and advanced primary healthcare system requires attention to the extent of nursing competence in municipal services. However, competence in complex and advanced care settings must be explored using perspectives which acknowledge the complexity of nurses' performance. A phenomenological hermeneutic, qualitative approach with individual in-depth interviews was used. COREQ reporting guidelines have been applied. A sample of eight nurses and two physicians employed in municipal in-patient acute care units (MAUs) were purposively recruited to participate. Data were collected between May and June of 2017. Analysis and interpretation were conducted systematically in three steps: naïve reading, structural analysis and comprehensive understanding. Two main themes were revealed. The first was the following: "The meaning of the individual nursing competence" including the themes "Having competence in clinical assessments, decision-making, and performing interventions"; "Having competence to collaborate, coordinate and facilitate"; and "Being committed." The second was the following: "The meaning of environmental and systemic factors for nursing competence," included the themes "Having professional leadership"; "Having a sufficiently qualified staff"; and "Working in an open, cooperative and professional work environment." Individual nursing competence in MAUs should include the capability to detect patient deterioration and to care for older patients in a holistic perspective. In addition, the professional environmental culture, supportive leadership and systemic factors seemed to be crucial to success. This study illustrates the nurses' responsibility for older patients' safety and quality of care in the MAUs. These findings can act as a foundation for the development and adaptation of educational programmes to accommodate requirements for nursing competence in MAUs. The broad perspective of nursing competence can give directions for quality improvements in MAUs.

Health Literacy: Implications for Child Health.

Health literacy is an important issue to consider in the provision of health-care to children. Similar to the adult population, most parents face health literacy challenges. Of particular concern, 1 in 4 parents have low health literacy, greatly affecting their ability to use health information to make health decisions for their child. High expectations are placed on parents and children to achieve effective disease management and positive health outcomes in the context of complex health-care systems and disease treatment regimens. Low health literacy affects parent acquisition of knowledge, attitudes, and behaviors, as well as child health outcomes across the domains of disease prevention, acute illness care, and chronic illness care. The effect of low health literacy is wide ranging, including 1) poor nutrition knowledge and behaviors, 2) higher obesity rates, 3) more medication errors, 4) more emergency department use, and 5) poor asthma knowledge, behaviors, and outcomes. Health-care providers can mitigate the effects of health literacy by seeking to align health-care demands with the health literacy skills of families. Effective health literacy-informed interventions provide insights into methods that can be used by providers and health systems to improve health outcomes. Health literacy-informed communication strategies should be used with all families in a "universal precautions approach" because all parents likely benefit from clear communication. As scientific advances are made in disease prevention and management, unless families understand how to follow provider recommendations, the benefit of these advances will not be realized and disparities in outcomes will be exacerbated.

Academic-Practice Partnerships: A Win-Win.

Partnerships between academia and practice can lead to improved patient care and health system innovations. Nurse educators in both academia and practice are positioned to facilitate opportunities for students and practicing nurses to be involved in evidence-based practice (EBP) care initiatives involving academic-health care partners in clinical and/or community-based systems. Best practices in collaborative partnerships have demonstrated the significance of their far-reaching impact on patients, students, direct care nurses, and health systems. Translation of EBP knowledge to practice transforms patient outcomes and empowers nurses to address the complexity of health care systems. This article describes the process and outcomes of an academic-practice partnership facilitated by nurse educators in both academic and practice settings. The impact of the adoption of EBP projects on clinical practice, students, and practicing nurses is described. National and international implications for academic- practice partnerships are discussed. [J Contin Educ Nurs. 2019;50(6):282-288.].

The challenge of de-labeling penicillin allergy.

Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. We performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928-2018 in Pubmed and Medline, search terms used included "penicillin allergy" or "penicillin hypersensitivity" alone or in combination with "adverse events," "testing," "evaluation," "effects," "label," "de-labeling," "prick or epicutaneous," and "intradermal" skin testing, "oral challenge or provocation," "cross-reactivity," and "antimicrobial stewardship". Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. Operationalizing penicillin allergy de-labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de-labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.