Opportunities For Improving Care Research Articles

26 Culturally informed developmental paediatric care: A qualitative study

Abstract Background Paediatricians provide developmental care through developmental surveillance, identification and management of specific developmental disorders, and health advocacy. Despite being one of the most common reasons to visit a paediatrician, the provision of care in this field is challenging as it intersects with medical, mental health, and educational systems. Additionally, the rise of international migration, inequities in health systems, and unique culturally based concepts of child development require paediatricians to have unique skills for culturally informed care provision in this area. Objectives A qualitative study was conducted to describe the perceptions of paediatricians on providing culturally informed developmental paediatric care to diverse populations. Design/Methods Semi-structured interviews were completed with paediatricians who primarily provide developmental care to understand the challenges, opportunities, and potential educational enhancements to improve culturally informed care for developmental paediatrics. Thematic analysis was used to analyze the transcribed interviews using inductive and deductive approaches. Results Three major themes emerged from 18 individual semi-structured interviews. The first theme, “cultural translation,” described language differences, interpretation, and trust-building between discordant physician/family dyads. The second theme, “inequity,” described systemic barriers that diverse populations experience, power distance in healthcare relationships, and pandemic-related amplifications of inequity. The third theme, “educational opportunities,” highlighted reflective practice opportunities, immersive experiences in diverse settings, and building a community of practice for paediatricians to build their knowledge base. Paediatricians practicing developmental paediatric care highlighted unique elements to the practice which may benefit from practice changes and curricular reform. Integration of meaningful training in the use of interpretation services, multicultural health brokers, and care coordination teams is a recommended intervention which is transferable to many disciplines. Peer-mentorship from colleagues of differing cultural backgrounds may help reduce race-based stereotypes and enhance perspective taking. Conclusion Paediatricians had a variety of perspectives on the provision of developmental paediatric care to diverse populations within Canada. There were a range of perceived opportunities for improvements in care noted on individual and systems levels. The development of infrastructure to build capacity in culturally informed developmental paediatric care to reduce culturally based health gaps is a needed future direction for developmental paediatrics.

Perceptions Toward Telemedicine of Health Care Staff in Nursing Homes in Northern Germany: Cross-Sectional Study.

Digitalization in the German health care system is progressing slowly, even though it offers opportunities for improvement of care. In nursing homes, most of the staff's work is paper based. Following the pandemic, there has been a decrease in the use of telemedicine applications. To ensure long-term implementation, the views of users, in this case nurses, are of interest. This cross-sectional study was conducted to describe which digital applications are already being used at inpatient care facilities, the attitude of nurses toward telemedicine, and for which areas the use of telemedicine in the facilities is considered appropriate by the participants. All inpatient care facility staff in Schleswig-Holstein were invited to participate in the survey from August 1 to October 31, 2022. The questionnaire consists of 17 determinants that ask about the attitude, use, and possible applications of telemedicine. In addition to a descriptive analysis, the influence of the general attitude toward telemedicine on various determinants was examined using the Fisher exact test for nominal variables and Spearman correlation coefficient for metric variables. A total of 425 caregivers participated in the survey. Of these respondents, 10.7% (n=41) currently used video consultations, and 76.1% (n=321) of the respondents were in favor of video consultations being practiced in training. Furthermore, 74.8% (n=312) of the respondents would attend a training on telephone medical consultation. Respondents indicated that video consultations have a small added value compared to asynchronous telemedicine (eg, sending photos). However, video consultations were perceived as somewhat less time-consuming than other communication channels. Video consultations are perceived as most useful for clarifying urgent problems. The respondents estimated that one in five paramedic calls at their facilities could be reduced through telemedicine approaches. It was important to the participants that telemedicine is as simple as possible and that there is a high level of data security. Although many caregivers have a positive attitude toward telemedicine and perceive its advantages, communication channels such as video consultation are still used infrequently in care facilities. To promote the use of telemedicine applications, it is important to emphasize their benefits. The presumed saving of paramedic calls thus represents a benefit, and it is crucial to train caregivers in the use of telemedicine to avoid uncertainties in dealing with the newer technologies. It is important to give them enough time and repetitions of the training.

In situ simulation in the intensive care unit: A phenomenological study of staff experiences.

To explore the experiences of clinical and non-clinical staff in an intensive care unit regarding the perceived benefits and drawbacks of using in situ simulation as a training tool. A descriptive phenomenological qualitative study was conducted among clinical and nonclinical ICU personnel. Simulations and interviews were conducted until data saturation was achieved. The interviews were recorded, transcribed verbatim for analysis, and interpreted using the Colaizzi method. Ten participant interviews generated data saturation. ISS was found to be feasible and beneficial in the ICU, facilitating experiential and emotion-based learning in real-world environments. Eight result categories were identified: simulation benefits, simulation benefits in real conditions, scenario authenticity, interference with usual work, ISS sessions, high-fidelity generating affective bonding, ISS as knowledge reinforcement, and recommendations for improvement. The fundamental structure revealed that ISS is perceived as an authentic and emotionally impactful team simulation modality that promotes experiential learning, reflection, and care improvement opportunities within the complex sociotechnical system of the ICU. All interviewees considered ISS to be a feasible simulation tool that should be implemented in the ICU to improve knowledge and skills, thereby enhancing teamwork.

CO54 Timely Rheumatoid Arthritis Control With Biologic or Targeted Synthetic DMARDs in Clinical Practice: Separating Successes From Opportunities for Care Improvement

CO54 Timely Rheumatoid Arthritis Control With Biologic or Targeted Synthetic DMARDs in Clinical Practice: Separating Successes From Opportunities for Care Improvement

Qualitative Analysis of the Lived Experience of Reproductive and Pediatric Health Care in the Military Health Care System.

Persistent inequities exist in obstetric and neonatal outcomes in military families despite universal health care coverage. Though the exact underlying cause has not been identified, social determinants of health may uniquely impact military families. The purpose of this study was to qualitatively investigate the potential impact of social determinants of health and the lived experiences of military individuals seeking maternity care in the Military Health System. This was an Institutional Review Board-approved protocol. Nine providers conducted 31 semi-structured interviews with individuals who delivered within the last 5 years in the direct or purchased care market. Participants were recruited through social media blasts and clinic flyers with both maximum variation and homogenous sampling to ensure participation of diverse individuals. Data were coded and themes were identified using inductive qualitative research methods. Three main themes were identified: Requirements of Military Life (with subthemes of pregnancy notification and privacy during care, role of pregnancy instructions and policies, and role of command support), Sociocultural Aspects of the Military Experience (with subthemes of pregnancy as a burden on colleagues and a career detractor, postpartum adjustment, balancing personal and professional requirements, pregnancy timing and parenting challenges, and importance of friendship and camaraderie in pregnancy), and Navigating the Healthcare Experience (including subthemes of transfer between military and civilian care and TRICARE challenges, perception of military care as inferior to civilian, and remote duty stations and international care). The unique stressors of military life act synergistically with the existing health care challenges, presenting opportunities for improvements in care. Such opportunities may include increased consistency of policies across services and commands. Increased access to group prenatal care and support groups, and increased assistance with navigating the health care system to improve care transitions were frequently requested changes by participants.

Measuring and improving quality in esophageal care and swallowing disorders.

Evaluating clinical care through quality-related metrics is increasingly common. There are now numerous quality statements and indicators related to the medical management of benign and pre-malignant esophageal diseases. Expert consensus leveraging evidence-based recommendations from published society guidelines has been the most frequently used basis for developing esophageal quality statements. While surgical care of patients with esophageal malignancies, including squamous cell carcinoma, has also been developed, those related to benign esophageal disease now include domains of diagnosis, treatment, and monitoring for gastroesophageal reflux disease, eosinophilic esophagitis (EoE), achalasia, and Barrett's esophagus (BE). Several recent studies evaluating adherence to quality metrics affirm substantial variation in practice patterns with opportunities for improvement in care across esophageal diseases. In particular, patient education regarding treatment options in achalasia, frequency of esophageal biopsies among patients with dysphagia to evaluate for EoE, and endoscopic evaluation within a BE segment are areas identified to have need for improvement. As the management of esophageal diseases becomes more complex and interdisciplinary, adherence to quality metrics may be a source of standardization and improvement in delivery and ultimately patient outcomes. Indeed, the development of national quality databases has resulted in a significant growth in the use of these metrics for quality improvement activities and may form the basis for future inclusion in quality reporting and payment programs.

Trans-disciplinary learnings from lived experience: person-centred integrated infertility care.

Introduction: Infertility is a stigmatising condition with profound psychosocial impacts. It is estimated it affects 48.5 million couples globally (Mascarenhas et al., 2012) and in the UK, one in seven couples have problems conceiving (NHS, 2020). Rates of infertility are increasing in both genders (Sun et al, 2019).
 Aims: To explore the lived experience of patients with infertility to identify opportunities for improvements in care and education of healthcare professionals (HCPs), and to investigate the potential of nutrition and lifestyle medicine as an adjunct to care.
 Methods: Critical reflections on a trans-disciplinary portfolio of seven publications about infertility authored or co-authored by a researcher with personal experience of infertility. These were published from 2015, and include peer-reviewed research articles, a case report, a textbook, a performance, creative artefacts including poems and a story. All embed patient voice as a fundamental element. The overall methodological framework adopted reflects a multi-lens interpretive, phenomenological, heuristic inquiry informed by a relativist ontology. Synthesis connectivity has been used to analyse the works, this approach is recommended by both Grant (2011) and Smith (2015). 
 Findings: Three research questions and findings were identified.
 1.How to improve care / outcomes? 
 Explored in publications 1, 2, 3, 4, 6, 7. Findings were optimal nutritional status and weight management supports fertility in both men and women, so nutrition care should be an integral part of care. Additionally, understanding the lived experience of infertility better facilitates effective care/counselling and improves patient experience. 
 2.How lived experience of infertility can shape clinical education/research?
 Explored in publications 2, 3, 4, 4a, 4b, 4c, 5, 6, 7. Findings were that co-creation of educational resources with people experiencing infertility, narratives of lived experience and interdisciplinary approaches have the potential to improve HCP & medical education; however, this needs to be aligned with involvement and engagement within research and curricula design.
 3.The role of gluten (a protein in grains) in infertility?
 Considered in publications 1,2,3,4,6,7. Gluten can negatively affect fertility in people diagnosed with coeliac disease, but fertility can also be affected in women with non-coeliac gluten sensitivity and more education is needed as professional awareness of the fertility implications of both coeliac disease and gluten sensitivity is low.
 Conclusions: Person-centred integrated infertility care needs to take account of the psycho-social impacts associated with infertility, include psycho-therapeutic support and also nutritional and lifestyle medicine. Where there is unexplained infertility or recurrent miscarriage, the potential role of gluten should be considered. Lived experience of infertility can be used as tool in HCP and medical education and socially to lessen stigmatisation and improve communication about infertility. Involvement needs to be aligned across the entirety of healthcare delivery, from clinical settings, through to both education and research (a 3-dimensional model called PRISM has been developed to triangulate involvement).

A CKD Clinical Decision Support System: A Cluster Randomized Clinical Trial in Primary Care Clinics

Rationale & ObjectiveThe study aimed to develop, implement, and evaluate a clinical decision support (CDS) system for chronic kidney disease (CKD) in a primary care setting, with the goal of improving of CKD care in adults. Study DesignCluster randomized trial. Setting & Participants32 midwestern primary care clinics were randomly assigned to either receive usual care or CKD-CDS intervention. Between April 2019 and March 2020, we enrolled 6,420 patients aged 18-75 years with laboratory-defined GFR categories of CKD Stage G3 and G4, as well as one or more of six CKD care gaps: absence of a CKD diagnosis, suboptimal blood pressure (BP) or glycated hemoglobin (A1C) levels, indication for angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) but not prescribed, a nonsteroidal anti-inflammatory agent (NSAID) on the active medication list, or an indicated nephrology referral. InterventionThe CKD-CDS provided personalized suggestions for CKD care improvement opportunities directed to both patients and clinicians at primary care encounters. OutcomesWe assessed the proportion of patients meeting each of 6 CKD-CDS quality metrics representing care gap resolution after18 months. ResultsThe adjusted proportions of patients meeting quality metrics in CKD-CDS versus usual care were as follows: CKD diagnosis documented (26.6% vs. 21.8%; RR 1.17, CI 0.91-1.51); ACEi/ARB prescribed (15.9% vs.16.1%;RR 0.95, CI 0.76-1.18); BP control (20.4% vs. 20.2%;RR 0.98, CI 0.84-1.15); A1C control (21.4% vs. 22.1%;RR 1.00, CI 0.80-1.24); NSAID not on the active medication list (51.5% vs. 50.4%;RR 1.03, CI 0.90-1.17); referral or visit to a nephrologist (38.7% vs. 36.1%;RR 1.02, CI 0.79-1.32). LimitationsWe encountered an overall reduction in expected primary care encounters and obstacles to point-of-care CKD-CDS utilization due to the COVID-19 pandemic. ConclusionThe CKD-CDS intervention did not lead to a significant improvement in CKD quality metrics. The challenges to CDS use during the COVID-19 pandemic likely influenced these results.

Survey Study of a Hospital-Based Bereavement Program During COVID-19: Insights to Improve Support of the Bereaved.

Background: The COVID-19 pandemic has highlighted that bereavement care is under-recognized with few hospitals offering universal bereavement services. Methods: One hundred sixty-nine bereaved individuals, whose loved ones died at our hospital during 2021 and 2022, completed a survey about their experience with the bereavement program. Results: Of respondents who recalled receiving bereavement outreach, 79% rated speaking to a team member soon after the death as having a positive impact on their bereavement, and 75% rated receiving a condolence call or note from the team positively. Feedback also identified opportunities for improvements in care: (1) importance of compassionate communication and connection with family members after a death; (2) more flexible hospital visitation policies; and (3) additional support for families during the end-of-life (EOL) period. Conclusions: The findings demonstrated that a hospital-based bereavement program can positively impact an individual's bereavement experience with a formal letter of condolence, psychoeducation information, and direct outreach from team members soon after death, being positively evaluated.

Expanding use of the HeartMate 3 ventricular assist device in pediatric and adult patients within the Advanced Cardiac Therapies Improving Outcomes Network (ACTION)

We report current outcomes in patients supported with the HeartMate 3 (HM3) ventricular assist device in a multicenter learning network. The Advanced Cardiac Therapies Improving Outcomes Network database was queried for HM3 implants between 12/2017 and 5/2022. Clinical characteristics, postimplant course, and adverse events were collected. Patients were stratified according to body surface area (BSA) (<1.4m2, 1.4-1.8m2, and >1.8m2) at device implantation. During the study period, 170 patients were implanted with the HM3 at participating network centers, with median age 15.3years; 27.1% were female. Median BSA was 1.68m2; the smallest patient was 0.73m2 (17.7kg). Most (71.8%) had a diagnosis of dilated cardiomyopathy. With a median support time of 102.5days, 61.2% underwent transplantation, 22.9% remained supported on device, 7.6% died, and 2.4% underwent device explantation for recovery; the remainder had transferred to another institution or transitioned to a different device type. The most common adverse events included major bleeding (20.8%) and driveline infection (12.9%); ischemic and hemorrhagic stroke were encountered in 6.5% and 1.2% of patients, respectively. Patients with BSA <1.4m2 had a higher incidence of infection, renal dysfunction, and ischemic stroke. In this updated cohort of predominantly pediatric patients supported with the HM3 ventricular assist device, outcomes are excellent with <8% mortality on device. Device-related adverse events including stroke, infection, and renal dysfunction were more commonly seen in smaller patients, highlighting opportunities for improvements in care.

Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different contextof care.

To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.

Diabetes care among individuals with and without schizophrenia in three Canadian provinces: A retrospective cohort study

ObjectiveDiabetes is present in approximately 10% of people living with schizophrenia and substantially contributes to early mortality, but some aspects of diabetes care among those with schizophrenia have been inadequately investigated to date. We assessed diabetes care and comorbidity management among people with and without schizophrenia. MethodsWe conducted a cohort study with data obtained from primary care electronic medical records stored in the Diabetes Action Canada (DAC) National Repository from Alberta, Ontario, and Quebec, Canada. The population studied included patients with diabetes, with and without schizophrenia, who had at least 3 primary care visits in a 2 year period between July 2017 and June 2019. Outcomes included glycemia; diabetes complication screening and monitoring; antihyperglycemic and cardioprotective medication prescription; health service use. ResultsWe identified 69,512 patients with diabetes; 911 (1.3%) of whom also had schizophrenia. Prevalence of high HbA1C (>8.5%) (9083/68601; 13.2% vs. 137/911; 15.0%) and high blood pressure (>130/80 mmHg) (4248/68601; 6.2% vs. 73/911; 8.0%) was similar between the two groups. Half (50.0%) of patients with schizophrenia (n = 455) had 11 or more primary care visits in the past year, compared with 27.8% of people without schizophrenia. (p < 0.0001). Patients with schizophrenia had lower odds of ever having blood pressure recorded (OR = 0.81, 95% CI 0.71–0.94) and fewer of those with chronic kidney disease (CKD) were prescribed renin-angiotensin aldosterone system inhibitors, compared to patients without schizophrenia (10.3% vs 15.8%, p = 0.0005). ConclusionsPatients with diabetes and schizophrenia achieved similar blood glucose and blood pressure levels to those without schizophrenia, and had more primary care visits. However, they had fewer blood pressure readings and lower prescription of recommended medications among those who also had CKD. These results are both encouraging and represent opportunities for improvement in care.

Virtual Discharge: Enhancing and Optimizing Care Efficiency for the Bedside Nurse.

Opportunities for care improvement exist within virtual care, which continues to emerge as an increasingly viable heath care option. Competing care priorities presented a challenge to nurse leaders, resulting in a modern solution to optimize resources using virtual care. A new model of care delivery, the virtual discharge (VDC) protocol, was established as a partnership between bedside nurses and a virtual nurse team. Using existing telehealth technology, virtual nurses delivered remote discharge education to patients on a 30-bed orthopedic unit. During the pilot, 269 VDC sessions totaled more than 101 hours of discharge education. Patient satisfaction communication scores improved significantly, and patients maintained a low 7-day readmission rate. This care model using emerging technology to deliver effective discharge education was highly satisfactory for patients and bedside nurses. Nurse leaders should seek opportunities to maximize the benefits of virtual technology in health care.

Progressive Influences of Family in Intensive Care Nursing Interventions: A Review

Introduction: This paper reviews the aspects of Family-Centered-Care (FCC) for patients in critical care nursing. FCC is an innovative and holistic approach consisting of planning, delivering, and evaluating the health care. It is mutually beneficial to the health and care of patients, their families, and especially the health care providers. Family members of the critically ill have a substantial role in the treatment trajectory of the patient, along with the nurses. FCC in critical care has opened a new dimension in improving the quality of care for the critically ill.Methods: A systematic search of five electronic bibliographic databases (CINAHL, Medline, EMBASE, Google Scholar, and Cochrane Database of Systematic Reviews) was undertaken. The keywords used were “Nursing,” “Intensive care,” “critical care,” and “Family Centred Care.”Findings: The review identifies the meaning of family involvement in the care of the critically ill patients and its positive outcomes on the health of the patient. FCC is developed under six categories: effects on patients, education and attitudes of nurses, effect on family and other factors (environmental, psychological and communication). Presence of a family member in the hospital ensures patients’ safety and provide sense of security and confidence to patients under care. The research highlighted the needs of the family who have critically ill patients admitted in intensive care units. It was observed that there is a lack of appropriate literature and qualitative methods to assess the needs and interventions for the care of the family, as the time of health care providers is distributed in giving the required nursing care interventions to the patient and following the hospital care protocols.Conclusion: The present literature review identified the importance of integrating FCC in the critical care units. This provides opportunities for improvement of care by involving and accommodating family members in the health team.

Preparing for participation in the centers for Medicare and Medicaid Services' bundle care payment initiative-advanced for major bowel surgery.

As healthcare costs rise, there is an increasing emphasis on alternative payment models to improve care efficiency. The bundled payment represents an alternative reimbursement model gaining popularity within the surgical sphere. We aimed to assess where the largest opportunities for care improvement lay and how best to identify patients at high risk of suffering costly complications. We utilized itemized CMS claims data for a retrospective cohort of patients between 2014 and 2016 who met inclusion criteria for the Major Bowel Bundled Payment Program and performed a cost analysis to identify opportunities for improved care efficiency. Based on the results of this cost analysis, we identified readmissions as a target for improvement. We then assessed whether the American College of Surgeons' National Surgical Quality Improvement Program surgical risk calculator (ACS NSQIP SRC) could accurately identify patients within our bundled payment population who were at high risk of readmission using a logistic regression model. Our study cohort included 252 patients. Readmissions accounted for 12.8% of the average total care episode cost with a coefficient of variation of 2.72, thereby representing the most substantial, non-fixed cost for our bundled payment patients. Patients readmitted within their 90-day care episode were 2.53 times more likely to be high-cost (>$60,000) than patients not readmitted. However, the ACS NSQIP SRC did not accurately predict patients at high risk of readmission within the first 30 days with an AUROC of 0.58. Our study highlights the importance of reducing readmissions as a central component of improving care for bowel surgery bundled payment patients. Preventing such readmissions requires accurate identification of patients at high risk of readmission; however, current risk prediction models lack the adaptability necessary for this task.

Eligibility for Posthospitalization Venous Thromboembolism Prophylaxis in Hospitalized Patients With COVID-19: A Retrospective Cohort Study.

Background A recent randomized trial, the MICHELLE trial, demonstrated improved posthospital outcomes with a 35-day course of prophylactic rivaroxaban for patients hospitalized with COVID-19 at high risk of venous thromboembolism. We explored how often these findings may apply to an unselected clinical population of patients hospitalized with COVID-19. Methods and Results Using a 35-hospital retrospective cohort of patients hospitalized between March 7, 2020, and January 23, 2021, with COVID-19 (MI-COVID19 database), we quantified the percentage of hospitalized patients with COVID-19 who would be eligible for rivaroxaban at discharge per MICHELLE trial criteria and report clinical event rates. The main clinical outcome was derived from the MICHELLE trial and included a composite of symptomatic venous thromboembolism, pulmonary embolus-related death, nonhemorrhagic stroke, and cardiovascular death at 35 days. Multiple sensitivity analyses tested different eligibility and exclusion criteria definitions to determine the effect on eligibility for postdischarge anticoagulation prophylaxis. Of 2016 patients hospitalized with COVID-19 who survived to discharge and did not have another indication for anticoagulation, 25.9% (n=523) would be eligible for postdischarge thromboprophylaxis per the MICHELLE trial criteria (range, 2.9%-39.4% on sensitivity analysis). Of the 416 who had discharge anticoagulant data collected, only 13.2% (55/416) were actually prescribed a new anticoagulant at discharge. Of patients eligible for rivaroxaban per the MICHELLE trial, the composite clinical outcome occurred in 1.2% (6/519); similar outcome rates were 5.7% and 0.63% in the MICHELLE trial's control (no anticoagulation) and intervention (rivaroxaban) groups, respectively. Symptomatic venous thromboembolism events and all-cause mortality were 6.2% (32/519) and 5.66% in the MI-COVID19 and MICHELLE trial control cohorts, respectively. Conclusions Across 35 hospitals in Michigan, ≈1 in 4 patients hospitalized with COVID-19 would qualify for posthospital thromboprophylaxis. With only 13% of patients actually receiving postdischarge prophylaxis, there is a potential opportunity for improvement in care.

How safe are paediatric emergency departments? A national prospective cohort study

BackgroundDespite the high number of children treated in emergency departments, patient safety risks in this setting are not well quantified. Our objective was to estimate the risk and type of...

A Comparative Survey Study of In-Person Versus Virtual Trauma Peer Review Meetings.

The American College of Surgeons Committee on Trauma mandates regular peer review meetings for verified trauma centers. The COVID-19 pandemic forced in-person meetings to transition to an online platform. The objective of this study was to assess the opinions of participants regarding the benefits and negative aspects of the virtual peer review process. We hypothesize that physicians and nurses would prefer a virtual meeting format. An anonymous online survey of members of the American Association for the Surgery of Trauma and the Society of Trauma Nurses was distributed in May and June of 2021. Demographic data and Likert scale-based responses were collected using the Research Electronic Data Capture platform. Invitations were sent to 1,726 physicians and 2,912 nurses. In total, 137 (8%) physicians and 141 (5%) nurses completed the survey. Both groups felt that either platform was effective in addressing opportunities for improvement in care. Physicians disagreed with the statement that anonymous online voting improved their ability to more accurately address opportunities for improvement. In total, 108 (79%) physicians and 100 (71%) nurses preferred a hybrid meeting. Only 18 (13%) physicians and 23 (16%) nurses wanted virtual meetings, whereas only 29 (21%) physicians and 36 (26%) nurses wanted in-person meetings going forward. Virtual and in-person trauma peer review meetings are equally effective in terms of case discussion and identifying opportunities for improvement in care. Given that most people preferred a hybrid meeting, future studies evaluating how best to incorporate and implement this format are needed.

Assessing the implementation of a clinical decision support tool in primary care for diabetes prevention: a qualitative interview study using the Consolidated Framework for Implementation Science

BackgroundIn this paper we describe the use of the Consolidated Framework for Implementation Research (CFIR) to study implementation of a web-based, point-of-care, EHR-linked clinical decision support (CDS) tool designed to identify and provide care recommendations for adults with prediabetes (Pre-D CDS).MethodsAs part of a large NIH-funded clinic-randomized trial, we identified a convenience sample of interview participants from 22 primary care clinics in Minnesota, North Dakota, and Wisconsin that were randomly allocated to receive or not receive a web-based EHR-integrated prediabetes CDS intervention. Participants included 11 clinicians, 6 rooming staff, and 7 nurse or clinic managers recruited by study staff to participate in telephone interviews conducted by an expert in qualitative methods. Interviews were recorded and transcribed, and data analysis was conducted using a constructivist version of grounded theory.ResultsImplementing a prediabetes CDS tool into primary care clinics was useful and well received. The intervention was integrated with clinic workflows, supported primary care clinicians in clearly communicating prediabetes risk and management options with patients, and in identifying actionable care opportunities. The main barriers to CDS use were time and competing priorities. Finally, while the implementation process worked well, opportunities remain in engaging the care team more broadly in CDS use.ConclusionsThe use of CDS tools for engaging patients and providers in care improvement opportunities for prediabetes is a promising and potentially effective strategy in primary care settings. A workflow that incorporates the whole care team in the use of such tools may optimize the implementation of CDS tools like these in primary care settings.Trial registration Name of the registry: Clinicaltrial.gov. Trial registration number: NCT02759055. Date of registration: 05/03/2016. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT02759055 Prospectively registered.

Preoperative in-hospital mortality in neonates with critical CHD.

Data regarding preoperative mortality in neonates with critical CHD are sparse and would aid patient care and family counselling. The objective of this study was to utilise a multicentre administrative dataset to report the rate of and identify risk factors for preoperative in-hospital mortality in neonates with critical CHD across US centres. The Pediatric Health Information System database was utilised to search for newborns ≤30 days old, born 1 January 2009 to 30 June 2018, with an ICD-9/10 code for d-transposition of the great arteries, truncus arteriosus, interrupted aortic arch, or hypoplastic left heart syndrome. Preoperative in-hospital mortality was defined as patients who died prior to discharge without an ICD code for cardiac surgery or interventional catheterisation. Overall preoperative mortality rate was at least 5.4% (690/12,739) and varied across diagnoses (d-TGA 2.9%, TA 8.3%, IAA 5.5%, and HLHS 7.3%) and centres (0-20.5%). In multivariable analysis, risk factors associated with preoperative mortality included preterm delivery (<37 weeks) (OR 2.3, 95% CI: 1.8-2.9; p < 0.01), low birth weight (<2.5 kg) (OR 3.8, 95% CI: 3.0-4.7; p < 0.01), and genetic abnormality (OR 1.6, 95% CI: 1.2-2.2; p < 0.01). Centre average surgical volume was not a significant risk factor. Approximately 1 in 20 neonates with critical CHD suffered preoperative in-hospital mortality, and rates varied across diagnoses and centres. Better understanding of the factors that drive the variation (e.g. patient factors, preoperative care models, surgical timing) could help identify patient care improvement opportunities and inform conversations with families.