A Web-based, Provider-driven Mobile App to Enhance Patient Care Coordination between Dialysis Facilities and Hospitals: Development and Pilot Implementation Study (Preprint)

BACKGROUND To fill the communication and care coordination gap between hospitals and dialysis facilities, we piloted a web-based, provider-driven mobile app (“DialysisConnect”). Here, we describe its development and pilot implementation. OBJECTIVE . METHODS DialysisConnect was developed iteratively, with focus group and user testing feedback, and made available to 106 potential users at one hospital [hospitalists, advanced practice providers (APPs), care coordinator] and four affiliated dialysis facilities (nephrologists, APPs, nurses/nurse managers) prior to the start of the pilot (11/1/20-5/31/21). Mid- and end-of-pilot online surveys of potential users were performed. Descriptive statistics were used to describe system usage patterns, ratings on multiple satisfaction items (1=not at all; 3=to a great extent), and provider-selected motivators and barriers to using DialysisConnect. RESULTS The pilot version of DialysisConnect included automatically uploaded clinical information from dialysis facilities, forms for entering critical admission and discharge information, and a direct communications channel. While physicians comprised most of the potential users of DialysisConnect, APPs and dialysis nurses were the most active users. Activity was unevenly distributed: e.g., one hospital-based APP recorded most of the admissions (n=225, 89%) and discharges (n=226, 93%) among patients treated at the pilot dialysis facilities. End-of-pilot ratings of DialysisConnect were generally higher for users vs. non-users: e.g., “I can see the potential value of DialysisConnect for my work with dialysis patients” [mean (SD): 2.8 (0.4) vs 2.3 (0.6), P=0.02]. Providers most commonly selected reduced time and energy spent gathering information as a motivator (42.3%) and lack of time to use the system as a barrier (30.8%). CONCLUSIONS In this pilot, we found that APPs and nurses were most likely to engage with the system. Survey participants generally viewed the system favorably, while identifying substantial barriers to its use. These results inform how best to motivate providers to use this and similar systems and inform future pragmatic research in care coordination in this and other populations.

Development of a Unified National Database of Burn Centers with Co-located Emergency Departments, 2020

The care of severely burned patients comes with unique requirements for specialized burn centers. The American Burn Association sets guidelines for burn centers and provides a voluntary program to verify their quality of care. However, not all burn centers are verified, and it is unclear which nonverified centers have met requirements set by their state health departments. To compile a complete database of all United States emergency departments in facilities with confirmed burn centers, we investigated state requirements to supplement data from the American Burn Association verification process. In 2020, only 13 states set requirements for burn centers; 3 states explicitly required American Burn Association verification, 4 used modified American Burn Association criteria, and 6 used alternate criteria. Only 2 states had separate requirements for pediatric burn centers. Based on adherence to state and American Burn Association criteria, we identified 90 confirmed burn centers in 2020, 85 of which had emergency departments. Of these 85, 45 (53%) were only verified, 17 (20%) were only state-confirmed, and 23 (27%) were both. Emergency departments in a confirmed burn center were more likely—than those without—to have higher adult and pediatric visit volumes, be academic, be a stroke or trauma (adult or pediatric) center, have a dedicated pediatric area, and have a pediatric emergency care coordinator. We compiled the first unified burn center database that incorporates state and American Burn Association lists. This database can be utilized in future health services research and is available to the public through a smartphone application.

Newborn Outcomes Among Veterans Utilizing VHA Maternity Benefits, 2016-2020

ABSTRACT Introduction Public Law 111-163 Section 206 of the Caregivers and Veteran Omnibus Health Services Act amended the Veterans Health Administration’s (VHA) medical benefits package to include 7 days of medical care for newborns delivered by Veterans. We examined the newborn outcomes among a cohort of women Veterans receiving VHA maternity benefits and care coordination. Materials and Methods We conducted a secondary analysis of phone interview data from Veterans enrolled in the COMFORT (Center for Maternal and Infant Outcomes Research in Translation) study 2016–2020. Multivariable regression estimated associations with newborn outcomes (preterm birth; low birthweight). Results During the study period, 829 infants were born to 811 Veterans. Mothers reported “excellent health” for 94% of infants. The prevalence of preterm birth was slightly higher in our cohort (11% vs. 10%), as were low birthweight (9%) deliveries, compared to the general population (8.28%). Additionally, 42% of infants in our cohort required follow-up care for non-routine health conditions; 11% were uninsured at 2 months of age. Adverse newborn outcomes were more common for mothers who were older in age, self-identified as non-white in race and/or of Hispanic ethnicity, had a diagnosis of posttraumatic stress disorder, or had gestational comorbidities. Conclusions The current VHA maternity coverage appears to be an effective policy for ensuring the well-being and health care coverage for the majority of Veterans and their newborns in the first days of life, thereby reducing the risk of inadequate prenatal and neonatal care. Future research should examine costs associated with extending coverage to 14 days or longer, comparing those to the projected excess costs of neonatal health problems. VHA policy should continue to support expanding care and resources through the Maternity Care Coordinator model.

“Caregiving is like on the job training but nobody has the manual”: Canadian caregivers’ perceptions of their roles within the healthcare system

Background Stepping into the role of an unpaid caregiver to offer help is often considered a natural expectation of family members or friends. In Canada, such contributions are substantial in terms of healthcare provision but this comes at a considerable cost to the caregivers in both health and economic terms. Methods In this study, we conducted a secondary analysis of a collection of qualitative interviews with 39 caregivers of people with chronic physical illness to assess how they described their particular roles in caring for a loved one. We used a model of caregiving roles, originally proposed by Twigg in 1989, as a guide for our analysis, which specified three predominant roles for caregivers – as a resource, as a co-worker, and as a co-client. Results The caregivers in this collection spoke about their roles in ways that aligned well with these roles, but they also described tasks and activities that fit best with a fourth role of ‘care-coordinator’, which required that they assume an oversight role in coordinating care across institutions, care providers and often advocate for care in line with their expectations. For each of these types of roles, we have highlighted the limitations and challenges they described in their interviews. Conclusions We argue that a deeper understanding of the different roles that caregivers assume, as well as their challenges, can contribute to the design and implementation of policies and services that would support their contributions and choices as integral members of the care team. We provide some examples of system-level policies and programs from different jurisdictions developed in recognition of the need to sustain caregivers in their role and respond to such limitations.

The Role Of The Pediatric Nurse In Discharge Planning; Identifying Gaps In Sri Lanka

Background: Pediatric discharge planning is a complex process, and that nurses need lengthy preparations. Role confusion among nurses will disrupt the smooth planning of the discharge. In Sri Lanka, although there is a possibility of reducing health costs through effective discharge planning led by pediatric nurses, it is questionable whether Sri Lankan nurses have clarified their role in this process.Method: This systematic review was conducted to map the different roles of nurses in the pediatric discharge planning process. Electronic databases of PubMed and CINAHL were searched for peer-reviewed journal articles among the pediatric population from 2005-2019, using the keywords such as discharge planning, pediatric nurse, care transitions, transitional care, and Sri Lankan nurse.Results: Articles that resulted in the word combination ‘Discharge planning and pediatric nursing (n=329) were used for screening. Two hundred and forty articles out of the nursing scope and sixty articles that do not describe an apparent nursing involvement in the discharge process were excluded, based on abstract review and full-text review, respectively. Sixteen studies were included in the final review. Few literature was found on the topic among Sri Lankan pediatric population. Four main categories of nurses’ roles were identified with the thematic analysis: discharge educator, discharge collaborator, post-discharge care coordinator, and family counselor. Conclusion: In Sri Lanka, no such defined roles of a nurse have been established yet in the discharge planning of pediatric patients. These roles may help nurses carry out discharge planning effectively, and future studies are needed on this topic in Sri Lanka.

Audit of the quality and content of discharge summaries from mental health inpatient units across Betsi Cadwaladr University Health Board

AimsOur aim was to carry out an audit of summaries sent from inpatient psychiatric units across North Wales (namely Heddfan in Wrexham, Ablett in Rhyl, and Hergest in Bangor), against recommendations from ‘Standards for Inpatient Mental Health Services’ (RCPsych 2014) and PRSB Mental Health Discharge guidelines (2018).MethodAblett summaries are typed onto and electronically sent through the Welsh Clinical Portal (WCP) directly to the GP. Hergest and Heddfan both have their own templates which are then sent to the GP and filed in the case notes. Data were collected from both sources. The first audit cycle used 25 discharges selected at random from the male and female open wards in each site (n = 75 summaries). Data were collected over 3 months time using the audit proforma.ResultAll mandatory headings are automatically inputted into the WCP summary used in Ablett therefore documentation was 100% for information such as patient name, DOB, and GP Details. Documentation of allergies was poor across 3 sites, particularly in Hergest, in which there was no mention of allergy status in 96% of summaries. Only 13% of Ablett summaries and 0% of Hergest summaries reach the GP on the day of discharge, however, 100% of summaries from Heddfan do, possibly due to their method of ‘discharge notification’. The date and location of discharge were documented in 84% of Heddfan summaries, 100% of Hergest summaries, and 100% of Ablett summaries. This implies that this heading is already incorporated into the templates for the 2 sites which scored 100%. In the Ablett, medication was documented in 88%, but we found that in 49% of discharge summaries, the medication was the only field filled in! In these cases, the GP may not even know why the patient had been admitted. This is clearly unacceptable. Risk history is poorly documented across the sites, with 0% in Hergest and Heddfan, and 12% in Ablett. 0% of summaries across the Health Board mentioned crisis contacts. 0% of summaries in Heddfan and Ablett contained details of the patient's care coordinator.ConclusionOur audit has identified a lack of psychiatry-relevant headings in the discharge summaries, particularly for those working in Ablett.

Physical health assessment quality improvement project

AimsMy aim was to ensure at least 60% of clients in the Acute Day Unit have a ‘physical screening tool’ entry.BackgroundAs a GP starting training in psychiatry I am very aware of the importance of physical health and the overlap between physical health and mental health. It has been found that there is a 20 year mortality gap for men and 15 year mortality gap for women in people with mental health problems. Thorncroft described this as ‘the scandal of premature mortality’.Nice Guidelines state: ‘Reducing premature mortality by improving physical healthcare for people with severe mental illness remains an NHS England priority. Funding has been made available to ensure that at least 60% of people who have severe mental illness receive NICE-recommended physical assessments and follow up from 2018/19 onwards.’The Acute Day Unit seemed to be the ideal situation to try to address this problem as clients are with us for 6-8 weeks during which time their physical health as well as their mental health can be optimised.MethodI emailed the whole team to invite ideas and questions regarding the QI project and discussed it further at the MDT meeting. It was important at the start to get the whole team on board. Having discussed it we decided to put six blocks of thirty minute slots weekly into the timetable for physical assessments. These were to be booked in by the client's care coordinator. I also added a column onto our team spreadsheet to input whether or not the physical assessment had been done. Frequent encouragements and reminders were sent round the team of which clients still needed a physical assessment.ResultBefore the changes were made 25% of clients were having their physical assessments done. After the changes were made 63% of clients had their physical assessment done, three of the twenty seven clients having only started at the day unit that week.ConclusionHaving made a change to the system of scheduling six regular slots for physical assessments there has been a dramatic rise in the number of clients having their physical assessment done. As this change has been to the system and will be continued automatically on the team calendar the improvement has been more easily sustained. We are keen to keep improving on this change with an ideal level of over 75% of clients having a physical health assessment.