Variation in Family Involvement on Rounds Between English-Speaking and Spanish-Speaking Families

BACKGROUND: Family-centered rounds (FCR) is the standard of care in inpatient pediatrics. Results of studies have revealed that Spanish-speaking families can experience communication challenges and decreased empowerment on rounds. In our study, we aim to identify variation in FCR practices for Spanish-speaking compared to English-speaking families and factors contributing to these disparities. METHODS: This is a cross-sectional observational study performed by secondary analysis of a quality improvement initiative conducted at a quaternary children’s hospital. Data were collected from June 2019 to March 2020 by using observational audits. Encounters were analyzed to compare key elements of FCR (including rounds location, elicitation of family questions, involvement in discharge planning) for English-speaking and Spanish-speaking families. Multivariable logistic regression was used to compare family involvement in FCR. A sensitivity analysis was conducted to evaluate unmeasured confounding. RESULTS: Rounding encounters included 394 families (261 English-speaking and 133 Spanish-speaking). Fewer Spanish-speaking families were included in the medical team’s discussion on rounds (64.7% vs 76.3%, P = .017), were asked about questions at the start of rounds (44.4% vs 56.3%, P = .025), or were involved in discussion of discharge criteria (72.2% vs 82.8%, P = .018) when compared to English-speaking families. These differences were magnified for resident teams rounding with subspecialists. The finding of decreased family involvement in the discussion on rounds persisted after adjusting for patient age and team type. CONCLUSIONS: Spanish-speaking families were less likely to be involved in FCR compared to English-speaking families. Further investigation is needed to explore the root causes of this practice variation and to develop interventions to address disparities.

Processo de alta hospitalar de pessoas com acidente vascular cerebral: uma revisão narrativa de literatura

O estudo objetivou a realização de uma revisão narrativa de literatura sobre o processo de alta hospitalar de pessoas com Acidente Vascular Cerebral (AVC). A busca foi realizada nas bases de dados, PubMed e Google Acadêmico, entre os meses de julho e agosto de 2021. Foram utilizados os descritores: “Stroke”, “discharge planning” OR “Transitional Care” AND “Caregivers”. Como critério de inclusão considerou-se publicações que abordaram o tema, publicadas entre os anos de 2016 a 2021, escritos em idioma português ou inglês e com acesso online. A pré-seleção considerou a leitura de título e resumo das publicaçãoes e classificou ao final 11 para leitura completa. Como principais resultados encontrou-se que o profissional mais envolvido no processo de alta hospitalar de pacientes acometidos por AVC é o enfermeiro (a). Entretanto, parece haver dificuldades no processo de transição do cuidado, principalmente no que se refere a comunicação e envolvimento dos pacientes e cuidadores na tomada de decisão. O planejamento da alta representa estratégia essencial para a transferência do paciente do hospital para casa e pode contribuir para a diminuição: das taxas de reinternação, das complicações, do tempo de internação hospitalar, dos custos de atendimento e de mortalidade. Ainda, destaca-se importância da educação em saúde e do trabalho interprofissional para o cuidado integral de pessoas com AVC.

OPTIMIZATION OF DISCHARGE PLANNING FOR COVID-19 PATIENTS THROUGH INTEGRATED EDUCATION SYSTEM COVID NURSE ASSISTANT (CNA) TO PREVENT TRANSMISSION AND IMPROVING PATIENT SELF-CARE ABILITY IN RSSA

The high number of COVID-19 cases was not balanced by the number of nurses assigned to the Covid isolation room with limited PPE availability. This causes many of the duties of nurses, especially health education, could not be performed completely. Thus, it is necessary to renew the Discharge Planning procedure for Covid 19 patients according to the characteristics of Covid-19 transmission. The purpose of this community service is to increase the effectiveness of the discharge planning for the COVID-19 patients to improve self-care and prevent infection transmission at home. This community service activity consists of 4 (four) stages, namely: 1) Preparation stage for coordination with the hospital; 2) Application development phase, consisting of application design, collection of educational media; 3) Implementation, launching and socialization of applications in the hospital environment; 4) Evaluation and monitoring stage. The results of the evaluation showed that as many as 58.7% of patients had used the CNA. About 62.7% patients experience an increase of their knowledge after accessing the CNA. There were 61.6% patients stated that the CNA had increased their knowledge on home care procedure post-Covid treatment. There are 62.3% of patients feel that the CNA supports patient care at home. The benefits of the CNA were expressed by 82 patients (87.2%) with increased self-care and as many as 76 patients (80.9%) stated that the CNA educational media was more attractive and easy to understand. The conclusion of this activity is that the CNA application can be implemented as a medium of health education for patients and families to improve their ability to take care of themselves.

Frailty and In-Hospital Mortality Risk Using EHR Nursing Data

Purpose The purpose of this study was to evaluate four definitions of a Frailty Risk Score (FRS) derived from EHR data that includes combinations of biopsychosocial risk factors using nursing flowsheet data or International Classification of Disease, 10th revision (ICD-10) codes and blood biomarkers and its predictive properties for in-hospital mortality in adults ≥50 years admitted to medical-surgical units. Methods In this retrospective observational study and secondary analysis of an EHR dataset, survival analysis and Cox regression models were performed with sociodemographic and clinical covariates. Integrated area under the ROC curve (iAUC) across follow-up time based on Cox modeling was estimated. Results The 46,645 patients averaged 1.5 hospitalizations (SD = 1.1) over the study period and 63.3% were emergent admissions. The average age was 70.4 years (SD = 11.4), 55.3% were female, 73.0% were non-Hispanic White (73.0%), mean comorbidity score was 3.9 (SD = 2.9), 80.5% were taking 1.5 high risk medications, and 42% recorded polypharmacy. The best performing FRS-NF-26-LABS included nursing flowsheet data and blood biomarkers (Adj. HR = 1.30, 95% CI [1.28, 1.33]), with good accuracy (iAUC = .794); the reduced model with age, sex, and FRS only demonstrated similar accuracy. The poorest performance was the ICD-10 code-based FRS. Conclusion The FRS captures information about the patient that increases risk for in-hospital mortality not accounted for by other factors. Identification of frailty enables providers to enhance various aspects of care, including increased monitoring, applying more intensive, individualized resources, and initiating more informed discussions about treatments and discharge planning.

Post-traumatic amnesia

Post-traumatic amnesia is the transient state of altered brain function that may follow a traumatic brain injury. At a practical level, an individual has emerged from post-traumatic amnesia when he or she is fully orientated and with return of continuous memory. However, the clinical manifestations are often more complex, with numerous cognitive domains commonly affected, as well as behaviour. In the acute setting, post-traumatic amnesia may easily go unrecognised; this is problematic as it has important implications for both immediate management and for longer-term prognosis. We therefore recommend its careful clinical assessment and prospective evaluation using validated tools. Patients in post-traumatic amnesia who have behavioural disturbance can be particularly challenging to manage. Behavioural and environmental measures form the mainstay of its treatment while avoiding pharmacological interventions where possible, as they may worsen agitation. Patients need assessing regularly to determine their need for further rehabilitation and to facilitate safe discharge planning.

Implementation of a patient progress diary for stoma patients living with dementia

With an ageing population and an increase in the prevalence of dementia, stoma care nurses (SCNs) are experiencing greater challenges in their role supporting this group of patients with their stoma care. Following concerns raised in our department by relatives about the care and teaching provided in this area, with patients occasionally denying having even seen an SCN, the need for a visual tool to enable timely interventions and increase knowledge for family, carers and ward staff became apparent. There is a comprehensive list of local and national guidelines underlining the need to provide more support and an increased comprehensive teaching plan specially tailored to dementia patients’ needs. The development of a patient progress diary, with a traffic light system showing each stage that the patient has reached, has provided a visual, up-to-date guide to the patient’s stoma management and highlights the need for further input to enable the patient to be discharged home safely and in a timely manner. The diary was formulated by the SCNs and printed by Coloplast, culminating in an easy-to-read booklet with a pictorial step-by-step guide to be inserted into patients’ washbags. The diary was reviewed by Great Western Hospitals Patient Advice and Liaison Service (PALS) and the Carers Committee, who provided positive feedback and subsequently supported the development of this patient-focused tool. Since introducing the diary, our team has decided to implement it with all patients, with positive feedback from patients, relatives, carers and ward staff. This has assisted in safe, timely and effective discharge planning.

Clinician estimates of prognosis: accuracy and impact—a retrospective inpatient hospice study

ObjectiveTo evaluate the accuracy and impact of clinicians’ estimates of prognosis (CEP) in patients referred for hospice inpatient care.MethodsRetrospective review of 12 months’ referrals to a London hospice unit. Data extracted included date of referral, admission and death and CEP.ResultsN=383. Mean age 72 years (range 24–101). CEP accuracy: Median survival where CEP was ‘days’ (n=141) was 7 days (0–164); CEP ‘weeks’ (n=167) was 14 days (1–538); CEP ‘months’ (n=75) was 32 days (2–507). Kaplan-Meier survival curves showed significant difference between CEP of ‘months’ and ‘weeks’ (p<0.0001); ‘months’ and ‘days’ (p<0.0001); but not ‘days’ and ‘weeks’ (p=0.1). CEP impact: admission waiting time increased with increasing CEP: CEP ‘days’ (n=105) median 1 day (0–14); CEP ‘weeks’ (n=154) median 2 days (0–46); CEP ‘months’ (n=69) median 3 days (0–46). No significant difference was demonstrated in the number of discharge planning conversations between groups (0.9/patient).ConclusionsCEP was accurate in over half of the cases but did not adequately discriminate between those with prognoses of days or weeks. CEP may affect the prioritisation given to patients by hospices. Inaccurate CEP on referral forms may influence other aspects of care; however, further research is needed.

Developing Best Practice Guidance for Discharge Planning Using the RAND/UCLA Appropriateness Method

Background: Discharge from acute mental health inpatient units is often a vulnerable period for patients. Multiple professionals and agencies are involved and processes and procedures are not standardized, often resulting in communication delays and co-ordination failures. Early and appropriate discharge planning and standardization of procedures could make inpatient care safer.Aim: To inform the development of a multi-component best practice guidance for discharge planning (including the 6 component SAFER patient flow bundle) to support safer patient transition from mental health hospitals to the community.Methods: Using the RAND/UCLA Appropriateness method, a panel of 10 professional stakeholders (psychiatrists, psychiatric nurses, clinical psychologists, pharmacists, academics, and policy makers) rated evidence-based statements. Six hundred and sixty-eight statements corresponding to 10 potential components of discharge planning best practice were rated on a 9-point integer scale for clarity, appropriateness and feasibility (median ≥ 7–9) using an online questionnaire then remote online face-to-face meetings.Results: Five of the six “SAFER” patient flow bundle components were appropriate and feasible for inpatient mental health. One component, “Early Flow,” was rated inappropriate as mental health settings require more flexibility. Overall, 285 statements were rated as appropriate and feasible. Forty-four statements were considered appropriate but not feasible to implement.Discussion: This consensus study has identified components of a best practice guidance/intervention for discharge planning for UK mental health settings. Although some components describe processes that already happen in everyday clinical interactions (i.e., review by a senior clinician), standardizing such processes could have important safety benefits alongside a tailored and timely approach to post-discharge care.