Multidisciplinary Care Coordination Research Articles

Going back to the ward-transitioning care back to the ward team.

Transition of care from the intensive care unit (ICU) to the ward is usually an indication of the patient's improving clinical status, but is also a time when patients are particularly vulnerable. The transition between care teams poses a higher risk of medical error, which can be mitigated by safe and complete patient handoff and medication reconciliation. ICU readmissions are associated with increased mortality as well as ICU and hospital length of stay (LOS); however tools to accurately predict ICU readmission risk are limited. While there are many mechanisms in place to carefully identify patients appropriate for transfer to the ward, the optimal timing of transfer can be affected by ICU strain, limited resources such as ICU beds, and overall hospital capacity and flow leading to suboptimal transfer times or delays in transfer. The patient and family perspectives should also be considered when planning for transfer from the ICU to the ward. During times of transition, families will meet a new care team, experience uncertainty of future care plans, and adjust to a different daily routine which can lead to increased stress and anxiety. Additionally, a subset of patients, such as those with new technology, require additional multidisciplinary support, education and care coordination which can contribute to longer hospital LOS if not addressed proactively early in the hospitalization while the patient remains in the ICU. In this review article, we describe key components of the transfer from ICU to the ward, discuss current strategies to optimize timing of patient transfers, explore strategies to partner with patients and families during the transfer process, highlight patient populations where additional considerations are needed, and identify future areas of exploration which could improve the care transition from the ICU to the ward.

INFLUENZA A PRECIPITATING MULTIORGAN FAILURE SYNDROME IN SICKLE CELL DISEASE

SESSION TITLE: Critical Care 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Management of sickle cell patients in the intensive care unit is challenging and requires multi-disciplinary care coordination. Multi-organ failure syndrome (MOFS) presents in a small portion of patients experiencing vaso-occlusive crises with or without acute chest syndrome, but can result in acute decompensation with a high mortality rate (1). We present a patient with influenza A who developed MOFS and was salvaged with an exchange transfusion. CASE PRESENTATION: 35 y/o African American male with HgSS sickle cell disease (SCD) who presented in a pain crisis with an acute kidney injury and transaminitis after experiencing flu-like symptoms, dark urine, and diffuse pain. Hb was 6 so he was transfused. Day 1 he developed acute renal failure and required hemodialysis. He required intubation and mechanical ventilation due to his low oxygenation and altered mental status. Day 2 he became hypotensive and was started on pressors. His chest radiograph had alveolar and interstitial opacities. Hg was still 6 so he received another 2U prbcs. Influenza A was positive and started on Tamiflu. HgSS was 44%, retic ct 9.7, haptoglobin 0, troponin 46, AST 1788, ALT 414, T bili 27.5. He underwent exchange transfusion promptly with 5 U prbcs with resulting HgSS of < 15%. P/F ratio improved from 183 to 260. Day 5 he developed a sick sinus node in the setting of septic shock requiring transvenous pacing. Day 12 he was extubated. Day 13 he developed bilateral subdural hematomas. He received more blood products and was transferred out of the ICU on Day 20. DISCUSSION: Among the acute crises that occur in sickle cell disease, acute chest syndrome is currently the only category which holds a strong recommendation for exchange transfusion. MOFS is rare in a sickle cell crisis, but has a high mortality and early recognition is key. It occurs in patients with significant hemolysis and is characterized by hemodynamic instability and compromise of at least two of three major organs (1). RBC transfusion is indicated (2), but the evidence for exchange transfusion in MOFS is less succinct (3). CONCLUSIONS: Influenza A can precipitate MOFS in SCD. Early recognition and timely exchange transfusion should be considered in MOFS, even in the initial absence of acute chest syndrome. Reference #1: 1. Hassell et al (1994). Acute multiorgan failure syndrome: a potentially catastrophic complication of severe sickle cell pain episodes. Am J Med. 96(2): 155-62. Reference #2: 2.Bernard et al (2016). Guidelines on red cell transfusion in sickle cell disease part II: indications for transfusion. British Journal of Haematology. 176:192-209. Reference #3: 3. Novelli, EM and MT Gladwin (2016). Crises in sickle cell disease. Contemporary Reviews in Critical Care Medicine. 149(4): 1082-1093. DISCLOSURES: No relevant relationships by Crystal Duran, source=Web Response No relevant relationships by Varsha Taskar, source=Web Response

Approach to frailty in the elderly in primary care and the community.

Frailty is a distinct clinical syndrome wherein the individual has low reserves and is highly vulnerable to internal and external stressors. Although it is associated with disability and multiple comorbidities, it can also be present in individuals who seem healthy. Frailty is multidimensional and its pathophysiology is complex. Early identification and intervention can potentially decrease or reverse frailty, especially in the early stages. Primary care physicians, community nurses and community social networks have important roles in the identification of pre-frail and frail elderly through the use of simple frailty screening tools and rapid geriatric assessments. Appropriate interventions that can be initiated in a primary care setting include a targeted medical review for reversible medical causes of frailty, medication appropriateness, nutritional advice and exercise prescription. With ongoing training and education, the multidisciplinary engagement and coordination of care of the elderly in the community can help to build resilience and combat frailty in our rapidly ageing society.

Returning to school: Parent preferences, perceptions, and preparedness.

72 Background: Neurocognitive late-effects (LE) are among the most pervasive complications of childhood cancer and can impact academic success. Successful transition back to school can be challenging and requires parents to be knowledgeable of potential LE and procedures necessary to secure support services. It can be unclear which oncology provider has responsibility for ensuring parents have such knowledge. Further, little is known about parent preferences, perceptions, or preparedness regarding neurocognitive LE and available supports. Methods: As part of a PCORI-funded engagement award, an online parent survey was developed and disseminated about neurocognitive LE and school-related challenges after treatment. Survey items were informed by qualitative analysis of parent interviews and stakeholder input. Parents were recruited nationally via stakeholder social media, and foundation emails and websites. Results: Of the 202 parents responding, 53% reported receiving information on possible treatment related cognitive or school problems from their healthcare team, while 55% reported needing to seek information independently. Information was most often provided by the oncologist (32%), nurse/social worker (26%), or psychologist/neuropsychologist (17%). Parent preferences for topics included information on learning difficulties, physical/health problems that could impact school, and resources for neurocognitive LE. Approximately half (55%) thought their healthcare team understood the issues facing survivors returning to school, although 47% reported that the team did not inquire about school issues or only asked general questions during follow up visits. A large proportion of parents (49%) reported feeling generally underprepared for their child’s return to school. Additional information on parent preferences as well as implications for program development, advocacy, and transition procedures will be discussed. Conclusions: Oncology providers are on the frontline of educating and preparing parents to meet the challenges of children’s return to school after childhood cancer. Improved multidisciplinary services and coordination of care to ensure successful transition back to school are needed.

Community-Based Home Health Programs and Chronic Disease: Synthesis of the Literature.

This article reviewed and evaluated literature on the various community-based home health programs and their effectiveness at preventing hospital admissions in adults. The research question addressed is as follows: Do community-based home health programs decrease hospital admissions in adult patients with chronic disease? The primary practice setting evaluated in this review of the literature was community-based home health programs. In this literature review, a seven-step review method was utilized to assess the evidence. Three electronic databases were used to conduct the initial search inquiry: CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus with Full Text, Medline, and PsycINFO. The search parameters include research from 2006 through 2016, English-language studies, and research published in peer-reviewed journals. The following search terms were used in multiple combinations: community-based health programs, chronic disease, and home. The primary sample population assessed was older adults with chronic disease. The research identified three common themes that influenced quality-of-life outcomes and health care utilization in participants of a community-based home health program. These themes were encouragement and emotional support, home visits, and multidisciplinary coordination of care. Additional concepts of depression and educational reinforcement were also noted. This literature review indicates that community-based home health programs are a viable solution to providing cost-effective health care to the adult population with chronic diseases. Community-based home health programs have been shown to have a positive impact on the quality of life and a decrease in health care utilization, including emergency department and primary care practitioner visits and hospital admissions, for adults with chronic disease.

Effects of integrated chronic care models on hypertension outcomes and spending: a multi-town clustered randomized trial in China

BackgroundHypertension affects one billion people globally and is one of the leading risk factors for cardiovascular and renal diseases. However, hypertension management remains poor, especially in rural China.MethodsA clustered randomized controlled trial was conducted in six towns in China’s Qianjiang county between 7/2012 and 6/2014, including 5462 hypertension patients above 35 years old. Six towns were randomly assigned to three groups: Group 1 had the integrated care model including a multidisciplinary team and continuous care coordination, Group 2 had both the integrated care model and provider-level financial incentives, and the control group had the usual care. Primary outcomes were systolic blood pressure and health-related quality of life measured by SF36; secondary outcomes included hypertension-related hospitalization rate and inpatient spending. Blood pressure was measured sixteen times bimonthly between 12/1/2011 and 6/30/2014, and quality of life was measured on 7/1/2012 and 6/30/2014. Inpatient data between 7/1/2010 and 8/31/2014 were used. This trial is registered at the World Health Organization’s International Clinical Trials Registry, number ChiCTR-OOR-14005563.ResultsWe found that the integrated care model effectively lowered blood pressure by 1.93 mmHg (95% CI 0.063–3.8), improved self-assessed health-related quality of life, and reduced the rate of hypertension-related hospitalization by 0.17 percentage points (95% CI 0.094–0.24). We also found that the provider-level financial contract further lowered blood pressure by 1.76 mmHg (95% CI 0.73–2.79) and reduced rates of hospitalization and inpatient spending, but it also reduced patients’ self-assessed health-related quality of life.ConclusionsIntegrated care and financial incentives are effective in lowering blood pressure and reducing hospitalization rate, but financial contracts may hurt patient quality of life.This trial was registered at the Chinese Clinical Trial Registry (ChiCTR-OOR-14005563) on November 23, 2014. It was a retrospective registration.

Delivery of radiation therapy in resource-limited settings: A pilot quality assessment study.

Progress has been made in resource-limited countries in treating acute lymphoblastic leukemia, but advances in solid malignancies have been slower. Multidisciplinary care coordination is challenging, assessing adherence to guidelines through quality improvement initiatives is essential. We characterized deviations from guidelines in the delivery of radiation in a middle-income country program as a pilot for evaluating adequacy of local control and as surrogate for integration of multidisciplinary care. One-third of patients for whom it was indicated did not receive radiation. Of the patients who received radiation, 95% had a deviation. This study underscores the importance of quality assessment in resource-limited settings.

An update on ocular allergy.

The update reviews prevalence, classification, cause, and treatment options for allergic eye disease. The incidence of allergic eye disease is underreported but may affect almost all patients with allergic rhinitis. Increased rates of oculonasal symptoms have been reported in the United States resulting in significant economic expenditures. The spectrum of allergic conjunctivitis and its differential considerations include seasonal and perennial conjunctivitis, vernal and atopic keratoconjunctivitis, and giant papillary conjunctivitis. Patients with allergic conjunctivitis have classic immunoglobulin E-mediated pathophysiology and treatments directed at allergen avoidance, traditional pharmacotherapy with oral antihistamines, topical dual-acting antihistamine/mast cell stabilizer agents, and treatment of tear film dysfunction are first-line management strategies. Immunotherapy is an effective treatment option and refractory cases may require ophthalmology comanagement for consideration of topical ester-based corticosteroid therapy and consideration of topical immunomodulators. Ocular allergy involving specific modifiable and treatable environmental sensitizations is common and often underrecognized. It can impair quality of life to varying degrees. Some cases are quite refractory to management and may require multidisciplinary coordination of care between allergy and ophthalmology specialists. Understanding classification, triggers, and treatment options is important in designing the most appropriate patient-tailored management plans.

Surgical readmissions: results of integrating pre-, peri- and postsurgical care.

AimsTo explore the feasibility of recruiting surgical oncology patients and implementing a surgical integrated discharge (SID) programme led by advanced practice providers (APP).BackgroundBurden of illness and complexity of treatment regimen makes it challenging for surgical oncology patients to participate in research. Surgical oncology nurses may have the necessary expertise to overcome this problem.DesignControlled longitudinal prospective observational study.MethodsThe SID programme included multidisciplinary care coordination, regular communication among APPs and proactive postdischarge follow‐up. Administrative databases were used to identify matching historical controls (n = 113) and evaluate programme outcomes.ResultsPatient enrolment was 84%. The main challenges for the programme implementation included incompatible health information systems among care settings, variation in care processes among hospital units and need for provider behaviour change.ConclusionsMost surgical oncology patients are willing to participate in outcomes programmes when contacted by familiar clinical personnel but programme implementation requires leadership support, communication among care teams and training and infrastructure.

Developing an Evidence-Based, Nurse-Led Psychoeducational Intervention With Peer Support in Gynecologic Oncology.

The physical and psychosocial impact of radiotherapy for gynecologic cancer requires complex interventions to address treatment-related, psychosocial, and psychosexual and survivorship needs. A multidisciplinary approach is required to address these needs, but standard practice is varied and lacks a sound evidence base. The aim of this study was to describe the process of development and pilot testing of a novel evidence-based, complex psychoeducational intervention aiming to improve psychosocial outcomes for gynecologic-oncology patients treated curatively with radiotherapy. The intervention combines tailored nursing consultations with telephone peer support pretreatment, midtreatment, end of treatment, and posttreatment. The UK Medical Research Council framework for developing complex interventions was used to produce an evidence-based, feasible, and acceptable intervention. Intervention manuals and study materials were informed by literature reviews of best-available evidence, relevant theory, and iterative consumer and expert consultations. The nurse manual specified content for consultations providing self-care information, coaching tailored to individual needs, and multidisciplinary care coordination. The peer manual described phone consultations aimed at providing psychosocial support and encouraging adherence to self-care strategies. Three peers and 1 nurse underwent rigorous skills and knowledge-based intervention delivery training. The intervention was pilot tested with 6 patients. Qualitative feedback led to minor design and content changes. The intervention was found to be feasible, relevant, and acceptable to participants and clinicians and is currently being tested in a national randomized controlled trial (PeNTAGOn). The Medical Research Council framework is useful in developing nursing interventions. The specific methods and strategies described are useful for designing future complex studies targeting patient supportive care.

Development of a multidisciplinary program for evaluation and treatment of pancreatic cancer in a community healthcare system.

303 Background: The incidence and mortality of pancreas cancer is rising in the United States. Only patients who are able to have complete (R0) resection have the potential of cure. Optimal surgical outcomes are influenced by local center volume and multidisciplinary support. We describe the development of a multidisciplinary approach to the evaluation and treatment of pancreas cancer in a community health care system. Methods: This project was initiated by the WellStar Cancer Program, encompassing 5 hospitals. An Institutional Guideline was developed, based upon NCCN, with refinements related to local capabilities and preferences. The Guideline emphasized the review of cases at a weekly tumor board for multidisciplinary coordination of care. Standards for staging evaluations, medical imaging, chemotherapy choices, radiation therapy, and surgical approach were included. A GI Nurse Navigator attended the conferences and assisted in the coordination of care. Specific outcomes were tracked by the Nurse Navigator and the Cancer Registry. Here we describe the program impact related to staging, treatment, nurse navigation, volume and outcomes during the 2011-2014 development phase of the program. Results: A total of 308 cases of pancreas cancer were captured by the registry in 2011-2014. 131 were diagnosed with stage IV disease and offered palliative therapy. 30 Stage I and 139 Stage II-III underwent staging evaluation and consideration of multidisciplinary care, summarized in the table below, and compared to a baseline registry cohort of the 4 preceding years. Conclusions: The development of a Multidisciplinary Team approach to pancreas cancer within a 5 hospital community system has led to improvement in treatment outcomes, including R0 resection rate. Full 2-year results to be updated at the meeting. [Table: see text]

Transitional Care to Reduce Heart Failure Readmission Rates in South East Asia.

Heart failure (HF) is an emerging public health problem due to increasing hospitalisations, readmissions and direct healthcare costs. Transitional care (TC) aims to improve multidisciplinary care coordination in HF and provides a streamlined strategy to ensure discharge success. This article reviews the different TC models and interventions in HF, and compares their strengths, weaknesses and efficacies. Notably, a nurse-led TC model under the direct administration of a dedicated multidisciplinary team appears to be the superior model of care. The emerging use of remote technology to track patient progress adds value, as human resources are scarce. Several knowledge gaps are highlighted in this article. The authors share their local institutional TC experience and discuss its early impact on HF care.

Optimizing Patient-centered Communication and Multidisciplinary Care Coordination in Emergency Diagnostic Imaging: A Research Agenda.

Patient-centered emergency diagnostic imaging relies on efficient communication and multispecialty care coordination to ensure optimal imaging utilization. The construct of the emergency diagnostic imaging care coordination cycle with three main phases (pretest, test, and posttest) provides a useful framework to evaluate care coordination in patient-centered emergency diagnostic imaging. This article summarizes findings reached during the patient-centered outcomes session of the 2015 Academic Emergency Medicine consensus conference "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The primary objective was to develop a research agenda focused on 1) defining component parts of the emergency diagnostic imaging care coordination process, 2) identifying gaps in communication that affect emergency diagnostic imaging, and 3) defining optimal methods of communication and multidisciplinary care coordination that ensure patient-centered emergency diagnostic imaging. Prioritized research questions provided the framework to define a research agenda for multidisciplinary care coordination in emergency diagnostic imaging.

Prospective roles for Canadian oncology nurses in breast cancer rapid diagnostic clinics.

The introduction of rapid diagnostic clinics for breast cancer increases oncology nurses' (ONs) responsibility for patient education and coordination of multidisciplinary care. Developed as an outcome of the E-Mentorship Oncology Nursing Program, this paper proposes new roles for these nurses to respond effectively and competently to such diagnostic innovation. The Oslo Manual Conceptual Framework of Innovation inspired the idea of change in prospective ONs' roles, corroborated by the Canadian Association of Nurses in Oncology's Standards of Practice and Competencies. New roles for ONs that are informed by the domain of information dynamics and evidence-based care are proposed.

Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse

Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR). We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR. Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15-4.44; P = .018). There were no differences in serious adverse events between groups. Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.

Bilateral Sensorineural Hearing Loss and Polyneuropathy in a Patient with Sweet's Syndrome.

Sweet's syndrome is an inflammatory systemic disease which has been associated with various underlying causes. The disease can involve multiple areas of the body including the skin and neurological system. There have been only two cases which have described otological involvement. This report presents a patient who developed loss of hearing secondary to Sweet's syndrome after developing cutaneous involvement along with peripheral neuropathy. Despite the patient's skin and neuropathy noticing improvement with intravenous immunoglobulin and azathioprine, he required bilateral cochlear implants for partial recovery of his hearing loss. This case highlights the need to recognize Sweet's syndrome as a complicated disease process where the role of otolaryngologists is important in the multidisciplinary coordination of care in both diagnosis and treatment.

Transfer from planned home birth to hospital: improving interprofessional collaboration.

Women's heightened interest in choice of birthplace and increased rates of planned home birth in the United States have been well documented, yet there remains significant public and professional debate about the ethics of planned home birth in jurisdictions where care is not clearly integrated across birth settings. Simultaneously, the quality of interprofessional interactions is recognized as a predictor of health outcomes during obstetric events. When care is transferred across birth settings, confusion and conflict among providers with respect to roles and responsibilities can adversely affect both outcomes and the experience of care for women and newborns. This article reviews findings of recent North American studies that examine provider attitudes toward planned home birth, differing concepts of safety of birthplace as reported by women and providers, and sources of conflict among maternity care providers during transfer from home to hospital. Emerging evidence and clinical exemplars can inform the development of systems for seamless transfer of women and newborns from planned home births to hospital and improve experience and perceptions of safety among families and providers. Three successful models in the United States that have enhanced multidisciplinary cooperation and coordination of care across birth settings are described. Finally, best practice guidelines for roles, communication, and mutual accommodation among all participating providers when transfer occurs are introduced. Research, health professional education, and policy recommendations for incorporation of key components into existing health care systems in the United States are included.

A heart failure initiative to reduce the length of stay and readmission rates.

The purpose of this pilot was to improve multidisciplinary coordination of care and patient education and foster self-management behaviors. The primary and secondary outcomes achieved from this pilot were to decrease the 30-day readmission rate and heart failure length of stay. The primary practice site was an inpatient medical-surgical nursing unit. The length of stay decreased from 6.05% to 4.42% for heart failure diagnostic-related group 291 as a result of utilizing the model. The length of stay decreased from 3.9% to 3.09%, which was also less than the national rate of 3.8036% for diagnostic-related group 292. In addition, the readmission rate decreased from 23.1% prior to January 2013 to 12.9%. Implementation of standards of care coordination can decrease length of stay, readmission rate, and improve self-management. Implementation of evidence-based heart failure guidelines, improved interdisciplinary coordination of care, patient education, self-management skills, and transitional care at the time of discharge improved overall heart failure outcome measures. Utilizing the longitudinal model of care to transition patients to home aided in evaluating social support, resource allocation and utilization, access to care postdischarge, and interdisciplinary coordination of care. The collaboration between disciplines improved continuity of care, patient compliance to their discharge regimen, and adequate discharge follow-up.

Interdisciplinary oncology education: A survey of trainees and program directors in the United States.

e17617 Background: High quality cancer treatment requires optimal coordination of multidisciplinary care. Therefore, oncologists must have a strong understanding of collaborating specialties. This ...

G91 US National Perspective on Hospitalisations of Children with Pre-existing Tracheostomy

Aims(1) To describe the reasons, duration, and cost of hospitalisations in children with pre-existing tracheostomy, (2) to assess how many of these hospitalisations might be avoidable.MethodsThis is a retrospective cohort...