Impact Care Delivery Research Articles

Moral Distress in the Neonatal Intensive Care Unit: What Is It, Why It Happens, and How We Can Address It.

Moral distress is prevalent in the neonatal intensive care unit (NICU), where decisions regarding end-of-life care, periviable resuscitation, and medical futility are common. Due to its origins in the nursing literature, moral distress has primarily been reported among bedside nurses in relation to the hierarchy of the medical team. However, it is increasingly recognized that moral distress may exist in different forms than initially described and that healthcare professions outside of nursing experience it. Advances in medical technology have allowed the smallest, sickest neonates to survive. The treatment for critically ill infants is no longer simply limited by the capability of medical technology but also by moral and ethical boundaries of what is right for a given child and family. Shared decision-making and the zone of parental discretion can inform and challenge the medical team to balance the complexities of patient autonomy against harm and suffering. Limited ability to prognosticate and uncertainty in outcomes add to the challenges faced with ethical dilemmas. While this does not necessarily equate to moral distress, subjective views of quality of life and personal values in these situations can lead to moral distress if the plans of care and the validity of each path are not fully explored. Differences in opinions and approaches between members of the medical team can strain relationships and affect each individual differently. It is unclear how the various types of moral distress uniquely impact each profession and their role in the distinctively challenging decisions made in the NICU environment. The purpose of this review is to describe moral distress and the situations that give rise to it in the NICU, ways in which various members of the medical team experience it, how it impacts care delivery, and approaches to address it.

“We’re keeping everything together with Band-Aids”: a case study of care work and family violence during a US oil boom

The Bakken region of the US recently experienced an oil boom, resulting in population growth and social change, including increased family violence. Drawing on care work literature, we ask: how might rural resource development impact the care work associated with services for domestic violence survivors? Utilising thematic analysis techniques, we examine data from in-depth interviews conducted with 50 care workers. We find that oil booms: (1) create more demand for care work; (2) lead to a scarcity of care workers; and (3) impact care delivery and burnout among care workers. Findings illustrate the importance of considering care as human infrastructure.

Chronic disease management models in nursing homes: a scoping review

ObjectivesNursing home (NH) residents experience a high burden of chronic disease. Chronic disease management (CDM) can be a challenge, as the context of care provision and the way care is...

Telehealth as a Tool for Quality Improvement in the Care of Pediatric Patients in Community Emergency Departments

Nearly 90% of pediatric emergency care is provided in a general emergency department (ED) that serve both adults and children. Many children in the United States do not live near an ED with a high level of pediatric readiness and many children are transferred to dedicated pediatric centers. Telemedicine provides an opportunity to impact care delivery systems to allow for children to be treated closer to home while maintaining high quality care. In this article, we will explore opportunities to use telemedicine in the emergency department and discuss incorporating quality improvement methodology to increase utilization of telehealth services.

Patient Disposition Patterns following Transurethral Resection of Bladder Tumor Vary Widely: SEER-Medicare Analyses of Postoperative Discharge Practices.

Following transurethral resection of bladder tumor, patients can be discharged home, observed for 24 hours or admitted to the hospital. While disposition can impact care delivery value, little is known about postoperative management patterns. We examined national trends and predictors of disposition following transurethral resection of bladder tumor. We queried SEER (Surveillance, Epidemiology, and End Results)-Medicare for patients who underwent transurethral resection of bladder tumor between 1994 and 2009. HCPCS (Healthcare Common Procedure Coding System) observation codes and admission and discharge dates were used to classify disposition as inpatient, ambulatory or 24-hour observation. Multivariable logistic regression was used to test associations between patient, facility and tumor level covariates and disposition status. We identified dispositions in 142,466 transurethral resections of bladder tumor, of which 107,784 (75.7%) were classified as ambulatory, 18,771 (13.2%) as inpatient and 15,911 (11.2%) as 24-hour observation. Patients with inpatient or 24-hour observation disposition were elderly (85 years old or older, OR 2.2), African American (OR 1.4) or Hispanic (OR 1.3), or infirm (Charlson comorbidity index 2 or higher, OR 1.5) or had large (greater than 5 cm, OR 1.6), high stage (3 OR 2.9 or 4, OR 3.5) tumors. Stent placement (OR 2.3) and restaging transurethral resection of bladder tumor (OR 1.8) were also associated with inpatient and 24-hour observation dispositions, while sequential resections were protective. Relative to 24-hour observation, individuals kept as inpatients were older (85 years old or older, OR 2.0), African American (OR 1.5) or Hispanic (OR 1.6), or infirm (Charlson comorbidity index 2 or higher, OR 1.7) or had large (greater than 5 cm, OR 1.1), high stage tumors (3 OR 2.1 or 4 OR 2.9). Temporal and geographic variations in disposition practice were identified. Disposition patterns are impacted by patient, tumor and treatment factors, and are heterogeneous following transurethral resection of bladder tumor. These data provide opportunities for care standardization and optimization in the value of care delivery for patients with bladder cancer.

The impact of governance in primary health care delivery: a systems thinking approach with a European panel

BackgroundEnhancing primary health care (PHC) is considered a policy priority for health systems strengthening due to PHC’s ability to provide accessible and continuous care and manage multimorbidity. Research in PHC often focuses on the effects of specific interventions (e.g. physicians’ contracts) in health care outcomes. This informs narrowly designed policies that disregard the interactions between the health functions (e.g. financing and regulation) and actors involved (i.e. public, professional, private), and their impact in care delivery and outcomes. The purpose of this study is to analyse the interactions between PHC functions and their impact in PHC delivery, particularly in providers’ behaviour and practice organisation.MethodsFollowing a systems thinking approach with data obtained through a three-round European Delphi process, we developed a framework that captures (1) the interactions between PHC functions by analysing correlations between PHC characteristics of participating countries, (2) how actors involved shaped these interactions by identifying the actor and level of devolution (or fragmentation) in the analysis, and (3) their potential effect on care delivery by exploring panellists’ opinions.ResultsA total of 59 panellists from 24 countries participated in the first round and 76% of the initial panellists (22 countries) completed the last round. Findings show correlations between governance, financing and regulation based on their degree of decentralisation. This is supported by panellists, who agreed that the actors involved in health system governance determine the type of PHC financing (e.g. ownership or payment mechanisms) and regulation (e.g. competences or gatekeeping), and this may impact care delivery and outcomes. Governance in our framework is an overarching function whose impact in PHC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PHC financing and regulation.ConclusionsThe application of this approach in policy implementation assessment intends to uncover limitations due to poor accountability and commitment to shared objectives. Its application in the design of health strategies helps foresee (and prevent) undesired or unexpected effects of narrow interventions. This approach will assist in the development of the realistic and long-term policies required for health systems strengthening.

Health care innovations across practice and academia: A theoretical framework

BackgroundAn innovation scholarly interest group used the Jobs to Be Done Theory from the business literature to provide insight into the solution-focused progress that nurses are trying to make in challenging situations. PurposeThis article presents a theoretical framework for understanding the progress nurses are trying to make through health care innovations across both practice and academic environments. MethodThis was a qualitative descriptive study using directed content analysis. We used the Jobs to Be Done Theory to guide the development of the semistructured questionnaire and the interpretation of findings. FindingsA theoretical framework of nursing innovations was derived to summarize and visually display the pathways and linkages of challenges, innovations, and impact domains of nursing innovations. Situations and opportunities arise within the context of interconnectedness and can lead to health care innovations in care delivery, patient care interventions, role transitions, research and translational methods, communication and collaboration, technology and data, teaching methods, and processes to improve care. DiscussionThis theoretical framework offers insight into the dynamic interactions of academic-practice partnerships for innovation. Workplace situations are interconnected and can result in needed innovations designed to impact care delivery.

Evaluating the impact of organisational digital maturity on clinical outcomes in secondary care in England

All healthcare systems are increasingly reliant on health information technology to support the delivery of high-quality, efficient and safe care. Data on its effectiveness are however limited. We therefore sought to examine the impact of organisational digital maturity on clinical outcomes in secondary care within the English National Health Service. We conducted a retrospective analysis of routinely collected administrative data for 13,105,996 admissions across 136 hospitals in England from 2015 to 2016. Data from the 2016 NHS Clinical Digital Maturity Index were used to characterise organisational digital maturity. A multivariable regression model including 12 institutional covariates was utilised to examine the relationship between one measure of organisational digital maturity and five key clinical outcome measures. There was no significant relationship between organisational digital maturity and risk-adjusted 30-day mortality, 28-day readmission rates or complications of care. In multivariable analysis risk-adjusted long length of stay and harm-free care were significantly related to aspects of organisational digital maturity; digitally mature hospitals may not only deliver more harm-free care episodes but also may have a significantly increased risk of patients experiencing a long length of stay. Organisational digital maturity is to some extent related to selected clinical outcomes in secondary care in England. Digital maturity is, however, also strongly linked to other institutional factors that likely play a greater role in influencing clinical outcomes. There is a need to better understand how health IT impacts care delivery and supports other drivers of hospital quality.

Contextual factors to registered nurse research utilisation in an Australian adult metropolitan tertiary intensive care unit: A descriptive study

BackgroundOrganisational and unit-level context can have a significant impact on implementation of evidence in practice, the latter being particularly important in the complex intensive care context. Evaluating the context may allow modifiable characteristics to be identified and addressed. ObjectivesThe objective was to examine the relationship between dimensions of the context and research utilisation in one intensive care unit. MethodsThis study used a quantitative cross-sectional survey. All registered nurses working in one Australian quaternary referral hospital intensive care unit were surveyed using the Alberta Context Tool and research utilisation instrument. Descriptive statistics were used, and bivariate analysis was undertaken to determine associations among demographic data, dimensions of context, and research utilisation. ResultsThe survey response rate was 33% (67/205). Most respondents were women with a mean of 8 years of intensive care nursing experience. The dimensions of culture, evaluation, informal interactions, structural/electronic resources, and organisational slack (time and space) were positively correlated with research utilisation. ConclusionsResearch utilisation was associated with numerous context dimensions, emphasising their effect on knowledge translation in this setting. Intensive care nurses are in a unique position to impact care delivery and provide evidence-based care to ensure optimal outcomes to patients at high risk of morbidity and mortality. Identified dimensions may be targeted and developed in future strategies to optimise the context for translating evidence into this complex practice environment.

Trends in Malware Attacks against United States Healthcare Organizations, 2016-2017

Introduction: The healthcare industry has begun seeing a new hazard develop against them- the threat of cyberattack. Beginning in 2016, healthcare organizations in the United States have been targeted for malware attacks, a specific type of cyberattack. During malware incidents hackers can lock users out of their own network to gain access to information or to hold the organization for ransom. With the increase in medical technology and the need for access to this information to provide critical care, this type of incident has the potential to put patient lives and safety at risk. Methods: A content analysis was conducted to assess the trend of attacks on healthcare organizations. U.S. Healthcare IT News and Becker's Hospital Review were used to collect all publicly reported malware attacks against U.S. healthcare organizations between 2016 and 2017. A fault-tree diagram was also developed to illustrate how hackers gain access to a healthcare network using malware. Results: There were 49 cases of malware attacks against U.S. HCOs identified. The attacks occurred across 27 states, and they took place during 18 out of 24 months. Six of the organizations reported paying ransom, whereas 43 organizations did not pay or did not report payment to the press. Impacts of these attacks range from network downtime to patient and staff records being breached. Discussion: Malware attacks have the potential to impact care delivery as well as the healthcare facility itself. Even though this study identified 49 malware attacks, we know this number is significantly higher based on data from HIMSS and the FBI. A reporting loophole exists in that hospitals are only required to report attacks in the case of breached protected health or financial data. For HCOs to fully understand the risk cyberthreats pose, it is important for attacks to become public information and for lessons learned to be shared. Future research reviewing identified attacks could help identify best practices for the healthcare industry to better prepare for cyberattacks.

Perspective on cultural competency: A review of Chinese culture.

With an emphasis on Chinese seniors, this article raises awareness of the importance of cultural competency and how this can impact care delivery, as well as strategies healthcare professionals can use to improve cultural competency in their institution.

Current and Emerging Trends in Point-of-Care Technology and Strategies for Clinical Validation and Implementation.

Point-of-care technology (POCT) provides actionable information at the site of care to allow rapid clinical decision-making. With healthcare emphasis shifting toward precision medicine, population health, and chronic disease management, the potential impact of POCT continues to grow, and several prominent POCT trends have emerged or strengthened in the last decade. This review summarizes current and emerging trends in POCT, including technologies approved or cleared by the Food and Drug Administration or in development. Technologies included have either impacted existing clinical diagnostics applications (e.g., continuous monitoring and targeted nucleic acid testing) or are likely to impact diagnostics delivery in the near future. The focus is limited to in vitro diagnostics applications, although in some sections, technologies beyond in vitro diagnostics are also included given the commonalities (e.g., ultrasound plug-ins for smart phones). For technologies in development (e.g., wearables, noninvasive testing, mass spectrometry and nuclear magnetic resonance, paper-based diagnostics, nanopore-based devices, and digital microfluidics), we also discuss their potential clinical applications and provide perspectives on strategies beyond technological and analytical proof of concept, with the end goal of clinical implementation and impact. The field of POCT has witnessed strong growth over the past decade, as evidenced by new clinical or consumer products or research and development directions. Combined with the appropriate strategies for clinical needs assessment, validation, and implementation, these and future POCTs may significantly impact care delivery and associated outcomes and costs.

Medicare Part B Status among Orthopaedic Surgery Providers in the United States

Health care delivery often focuses on treatments over provider and payment attributes, which also impact care delivery. This study describes the procedures, allowed charges, submitted charges, and payments for orthopaedic providers that accept Medicare Part B in the US. Additionally, the study investigated regional and gender differences in charges and payments. We used the national Medicare Part B Provider Utilization and Payment data released from the CMS in April 2014. Analyses were conducted on US providers that identified as orthopaedic surgeons. There was a major gender disparity in orthopaedic providers and charges. Average allowed charges, submitted charges, and payments were generally the same across all regions except for region 6. Extreme differences between allowed charges and submitted charges were evident. The most frequent procedures across all regions were x-ray exams and raises questions about overutilization of diagnostic imaging in orthopaedics.

Development of Vignettes to Explore Workplace Bullying

ABSTRACTIncivility and bullying in healthcare can impact care delivery and quality. There are challenges in research to making a direct link between the behaviors and patient outcomes. One way to address the challenges is through the creation of bullying vignettes that induce mood changes that reflect a feeling of being bullied. The purpose of this study was to develop workplace bullying textual vignettes and to test content validity. Cognitive interviewing was used by engaging content experts to rate 21 author-created vignettes for relevance, realism, and severity. Eleven vignettes were identified and have potential use in research, education, and practice.

An introduction to nursing surveillance in the tele-ICU

An introduction to nursing surveillance in the tele-ICU

Evolving Federal and State Health Care Policy: Toward a More Integrated and Comprehensive Care-Delivery System for Children With Medical Complexity.

Irrespective of any future changes in federal health policy, the momentum to shift from fee-for-service to value-based payment systems is likely to persist. Public and private payers continue to move toward alternative payment models that promote novel care-delivery systems and greater accountability for health outcomes. With a focus on population health, patient-centered medical homes, and care coordination, alternative payment models hold the potential to promote care-delivery systems that address the unique needs of children with medical complexity (CMC), including nonmedical needs and the social determinants of health. Notwithstanding, the implementation of care systems with meaningful quality measures for CMC poses unique and substantive challenges. Stakeholders must view policy options for CMC in the context of transformation within the overall health system to understand how broader health system changes impact care delivery for CMC.

Abstract TP396: Strategies for Successful Stroke Survey

Background: Comprehensive Stroke Center (CSC) certification has been available since 2012. Over 100 hospitals have completed this rigorous advanced disease specific certification. Stroke certification occurs every two years and can be resource intensive for hospitals. No matter how experienced a center is, preparation of the extended team takes considerable time and energy. Issue: Stroke Centers operate in a dynamic healthcare environment, continuously undergoing series of changes that impact care delivery across the continuum. In theory, survey preparation is an on-going process. In reality people get comfortable once certified and return to previous workflows with less attention to detail. Current literature focuses on improved quality and outcomes that result from disease specific certification. There is a limited amount of published literature regarding stroke survey preparation activities, and available publications are over ten years old. Purpose: The purpose of this presentation is to formally contribute successful survey strategies to the experience of the stroke community. Method: Various aspects of preparation, including team development, standards and clinical practice guidelines review, the role of data, and methods to prepare staff will be discussed. In addition the use of resources, the value of pre-survey consultation to provide external gap analysis, and equitable distribution of preparation activities will be explored. Result: Thorough survey preparation has led to an initial survey and two recertifications with a total of 11 RFIs. Multidisciplinary teamwork requires ongoing commitment to assure adoption of standards and continued engagement to ensure all involved areas are ready to actively participate in the on-site review process. Conclusion: More research and publication is needed to assist stroke centers to prepare for a successful stroke survey. As CSC’s mature expectations are increased to grow the way programs meet the needs of presenting stroke patients and develop the professional team. By comparing and sharing strategies, comprehensive stroke programs can share experiences that lead to decreased stress and improved confidence at the time of on-site certification visit

Delivering high quality hip fracture rehabilitation: the perspective of occupational and physical therapy practitioners

Aim: The majority of post-acute hip fracture rehabilitation in the US is delivered in skilled nursing facilities (SNFs). Currently, there are limited guidelines that equip occupational and physical therapy practitioners with a summary of what constitutes evidence-based high quality rehabilitation. Thus, this study aimed to identify rehabilitation practitioners’ perspectives on the practices that constitute high quality hip fracture rehabilitation.Methods: Focus groups were conducted with 99 occupational and physical therapy practitioners working in SNFs in southern California. Purposive sampling of facilities was conducted to capture variation in key characteristics known to impact care delivery for this patient population (e.g., financial resources, staffing, and patient case-mix). Questions aimed to elicit practitioners’ perspectives on high quality hip fracture rehabilitation practices. Each session was audio-recorded and transcribed. Data were systematically analyzed using a modified grounded theory approach.Results: Seven themes emerged: objectives of care; first 72 h; positioning, pain, and precautions; use of standardized assessments; episode of care practices; facilitating insight into progress; and interdisciplinary collaboration.Conclusions: Clinical guidelines are critical tools to facilitate clinical decision-making and achieve desired patient outcomes. The findings of this study highlight the practitioners’ perspective on what constitutes high quality hip fracture rehabilitation. This work provides critical information to advance the development of stakeholder-driven rehabilitation clinical guidelines. Future research is needed to verify the findings from other stakeholders (e.g., patients), ensure the alignment of our findings with current evidence, and develop measures for evaluating their delivery and relationship to desired outcomes.Implications for RehabilitationThis study highlights occupational and physiotherapy therapy practitioners’ perspectives on the cumulative best practices that reflect high quality care, which should be delivered during hip fracture rehabilitation.While this study was limited to two professions within the broader interdisciplinary team, consistently occupational and physiotherapy therapy practitioners situated their role and practices within the team, emphasizing that high quality care was driven by collaboration among all members of the team as well as the patient and caregivers.Future research needs to evaluate the (a) frequency at which these practices are delivered and the relationship to patient-centered outcomes, and (b) perspectives of rehabilitation practitioners working in other PAC settings, patients, caregivers, as well as the other members of the interdisciplinary PAC team.

ARE HIGHER HOSPITAL APPROPRIATENESS SCORES FOR PERCUTANEOUS CORONARY INTERVENTION LINKED TO FEWER 30-DAY READMISSIONS?

Institutional programs aimed at improving PCI appropriateness may impact care delivery through better process control, measurement, and infrastructure, potentially affecting other outcomes like 30-day readmissions. This retrospective cohort study included 31 hospitals performing both elective and

The five key things you need to know to manage adult patients with sickle cell disease.

The lack of a strong evidence base to guide the management of adults with sickle cell disease (SCD) makes it difficult for patients to receive high quality care outside of specialty centers. As there is a dearth of providers with sickle cell expertise, the purpose of this article is to identify some of the key things every provider who manages the care of adults with SCD should know. Managing adults with SCD requires excellent clinical skills, as it can affect every organ and cause life-threatening complications but it also requires a willingness to manage patients who often have psychosocial issues that are complex and impact care and care delivery in very significant ways. We have chosen topics for which there is a limited evidence base but which have significant clinical consequences if left unrecognized or poorly managed. The topics that will be addressed include chronic pain, neurocognitive dysfunction, renal disease, venous thromboembolism, and avoiding the inappropriate use of red cell transfusions.