scholarly journals 274 From Clinical Care Programme to Frailty Pathway; a Multidisciplinary, Interagency Journey

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Amanda Casey ◽  
Chie Wei Fan ◽  
Joseph Duggan
Keyword(s):  
Older Persons ◽  
Care Pathway ◽  
Clinical Care ◽  
Service Planning ◽  
Healthcare Organisation ◽  
Readmission Rates ◽  
Care Programme ◽  
Community Healthcare ◽  
Complex Needs ◽  
Steering Group

Abstract Background The National Clinical Programme for Older Persons was introduced in the Model 4 Adult teaching hospital in 2012 with the development of a Specialist Geriatric Ward, supported by an existing Day Hospital and access to post acute rehabilitation in the local model 3 hospital. The continuing growth of the population over 70 years in the catchment area and the increasing awareness of the complex needs of this group of patients required a new way of thinking and working. Methods Using Lean methodology the group restructured the focus of the care pathway for older persons using evidence based practice and data collection. Workstreams have been identified and iterative project charters established to guide and empower staff to design and evaluate the supports they provide. Key internal and external stakeholders were identified and invited to participate in the ongoing steering group and the voice of the customer was used to underpin targeted improvements. Results The hospital now has a structured framework for the delivery and evaluation of care provided to older persons attending our services. Overall governance is provided by a Frailty Steering Group with strong clinical leadership and is informed by agreed quality indicators and realtime data. Despite increases in numbers requiring admission, length of stay has decreased, readmission rates have remained stable and a greater proportion of our patients are accessing both offsite rehabilitation and home supports on discharge. Conclusion This is an ongoing project with medium and long term goals identified across all workstreams. The evidence and data gathered will inform service planning and resource allocation. A number of collaborative research proposals are now being considered from across acute hospital and Community Healthcare Organisation.

scholarly journals 187 Capturing the Providers of Services to Older Persons – An Exercise in Integration of Care

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Patrice Reilly ◽  
Frances Dockery ◽  
Una O'Leary ◽  
Sinead Grogan ◽  
Joan Walsh ◽  
...  
Keyword(s):  
Health Services ◽  
Older Persons ◽  
Small Region ◽  
Healthcare Organisation ◽  
Integration Of Care ◽  
Vast Number ◽  
Community Healthcare ◽  
Care Services ◽  
Health And Social Care ◽  
Health Diagnosis

Abstract Background There is much focus on the dearth of resources within healthcare systems, with a focus on health services. In 2018, we held a speed networking event for two local areas of a HSE Community Healthcare Organisation. This highlighted the vast array of supports available to assist older people to live well. This, alongside a Listening to Older Person’s Workshop, highlighted the need for a local directory of services. Methods In considering potential networking attendees, a social determinants of health approach (Dahlgren and Whitehead, 1991) was adopted to scope all supports available across community, acute, voluntary and statutory health and social care services within the area. This was expanded on further to develop the directory. Results The directory provides details of 358 organisations, individuals and groups available to support older persons within a catchment area with a population of 13,833 older persons (CSO Census, 2016). Hospital services comprised 27 of these while community HSE and GP health services made up 130. The remaining 201 were local and national NGOs and community groups ranging in service provision, a sample of which as follows: 39 provided some level of social/education engagement, three befriending, 18 counselling, five housing specific, 11 substance dependency, 12 provided supports to persons impacted by abuse. A further 20 national NGOs provided a local service or helpline with a focus on a particular health diagnosis. Conclusion This exercise shows the vast number of services available within just one small region, to support older persons to live well at home. The directory has been approved as a template for other networks in the CHO. It is being adapted into an online version by an interagency group. Using this template nationally has the potential to overcome gaps in health service resources, and support true integration, in line with the ICPOP (2016) 10 step framework.

scholarly journals MP08-05 REDUCED LENGTH OF STAY AND READMISSION RATES USING A STANDARDIZED CLINICAL CARE PATHWAY FOLLOWING ROBOTIC PROSTATECTOMY

2016 ◽  
Vol 195 (4S) ◽  
Author(s):  
George Turini ◽  
Melissa Clark ◽  
Christopher Tucci ◽  
Jason Machan ◽  
Dragan Golijanin ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Care Pathway ◽  
Clinical Care ◽  
Robotic Prostatectomy ◽  
Readmission Rates ◽  
Clinical Care Pathway

A Clinical Care Pathway to Reduce ICU Usage in Head and Neck Microvascular Reconstruction

2018 ◽  
Vol 160 (5) ◽  
pp. 783-790 ◽  
Author(s):  
Elliot Morse ◽  
Cara Henderson ◽  
Tracy Carafeno ◽  
Jacqueline Dibble ◽  
Peter Longley ◽  
...  
Keyword(s):  
Intensive Care ◽  
Length Of Stay ◽  
Head And Neck ◽  
Surgical Complications ◽  
Readmission Rate ◽  
Care Pathway ◽  
Clinical Care ◽  
Readmission Rates ◽  
Icu Admission ◽  
Clinical Care Pathway

Objective To design and implement a postoperative clinical care pathway designed to reduce intensive care usage on length of stay, readmission rates, and surgical complications in head and neck free flap patients. Methods A postoperative clinical care pathway detailing timelines for patient care was developed by a multispecialty team. In total, 108 matched patients receiving free tissue transfer for reconstruction of head and neck defects in the year before (prepathway), year after (early pathway), and second year after (late pathway) pathway implementation were compared based on postoperative length of stay, 30-day readmission rate, intensive care unit (ICU) admission, and rates of medical/surgical complications. Results Median length of stay decreased from 10 to 7.5 and 7 days in the pre-, early, and late-pathway groups, respectively ( P = .012). Readmission rate decreased from 16% in the prepathway group to 0% and 3% in the early and late-pathway groups. The number of patients admitted to the ICU postoperatively decreased from 100% to 36% and 6% in the pre-, early, and late-pathway groups, respectively ( P = .025). The rates of surgical and medical complications were equivalent. Discussion This pathway effectively reduced ICU admission, length of stay, and readmission rates, without increasing postoperative complications. These outcomes were sustainable over 2 years. Implications for Practice Free flap patients may not require routine ICU admission and may be taken off ventilatory support in the operating room. This effectively reduces costly resource use in this patient population. Similar pathways could be introduced at other institutions.

Retrospective Review and Proof of Concept of Asia’s First Mobile Stroke Unit Experience in Kovai Medical Center and Hospital

2020 ◽  
Vol 3 (2) ◽  
pp. 116-123
Author(s):  
Mathew Cherian ◽  
Pankaj Mehta ◽  
Shriram Varadharajan ◽  
Santosh Poyyamozhi ◽  
Elango Swamiappan ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Retrospective Review ◽  
Stroke Unit ◽  
Care Pathway ◽  
Clinical Care ◽  
Stroke Care ◽  
First Year ◽  
Proof Of Concept ◽  
Mobile Stroke Unit ◽  
Clinical Care Pathway

Background: We review our initial experience of India’s and Asia’s first mobile stroke unit (MSU) following the completion of its first year of operation. We outline the clinical care pathway integrating the MSU services using a case example taking readers along our clinical care workflow while highlighting the challenges faced in organizing and optimizing such services in India. Methods: Retrospective review of data collected for all patients from March 2018 to February 2019 transported and treated within the MSU during the first year of its operation. Recent case example is reviewed highlighting complete comprehensive acute clinical care pathway from prehospital MSU services to advanced endovascular treatment with focus on challenges faced in developing nation for stroke care. Results: The MSU was dispatched and utilized for 14 patients with clinical symptoms of acute stroke. These patients were predominantly males (64%) with median age of 59 years. Ischemic stroke was seen in 7 patients, hemorrhagic in 6, and 1 patient was classified as stroke mimic. Intravenous tissue plasminogen activator was administered to 3 patients within MSU. Most of the patients’ treatment was initiated within 2 h of symptom onset and with the median time of patient contact (rendezvous) following stroke being 55 mins. Conclusion: Retrospective review of Asia’s first MSU reveals its proof of concept in India. Although the number of patients availing treatment in MSU is low as compared to elsewhere in the world, increased public awareness with active government support including subsidizing treatment costs could accelerate development of optimal prehospital acute stroke care policy in India.

scholarly journals Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jennifer Mann ◽  
Fintan Thompson ◽  
Robyn McDermott ◽  
A. Esterman ◽  
Edward Strivens
Keyword(s):  
Older People ◽  
Older Persons ◽  
Hospital Admissions ◽  
Community Dwelling ◽  
Trial Registration ◽  
Significant Finding ◽  
Complex Needs ◽  
Primary Practice ◽  
The Impact ◽  
Open Arch

Abstract Background Health systems must reorient towards preventative and co-ordinated care to reduce hospital demand and achieve positive and fiscally responsible outcomes for older persons with complex needs. Integrated care models can improve outcomes by aligning primary practice with the specialist health and social services required to manage complex needs. This paper describes the impact of a community-facing program that integrates care at the primary-secondary interface on the rate of Emergency Department (ED) presentation and hospital admissions among older people with complex needs. Methods The Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) study is a multicentre randomised controlled trial with a stepped wedge cluster design. General practitioners (GPs; n = 14) in primary practice within the Cairns region are considered ‘clusters’ each comprising a mixed number of participants. 80 community-dwelling persons over 70 years of age if non-Indigenous and over 50 years of age if Indigenous were included at baseline with no new participants added during the study. Clusters were randomly assigned to one of three steps that represent the time at which they would commence the OPEN ARCH intervention, and the subsequent intervention duration (3, 6, or 9 months). Each participant was its own control. GPs and participants were not blinded. The primary outcomes were ED presentations and hospital admissions. Data were collected from Queensland Health Casemix data and analysed with multilevel mixed-effects Poisson regression modelling to estimate the effectiveness of the OPEN ARCH intervention. Data were analysed at the cluster and participant levels. Results Five clusters were randomised to steps 1 and 2, and 4 clusters randomised to step 3. All clusters (n = 14) completed the trial accounting for 80 participants. An effect size of 9% in service use (95% CI) was expected. The OPEN ARCH intervention was found to not make a statistically significant difference to ED presentations or admissions. However, a stabilising of ED presentations and a trend toward lower hospitalisation rates over time was observed. Conclusions While this study detected no statistically significant change in ED presentations or hospital admissions, a plateauing of ED presentation and admission rates is a clinically significant finding for older persons with complex needs. Multi-sectoral integrated programs of care require an adequate preparation period and sufficient duration of intervention for effectiveness to be measured. Trial registration The OPEN ARCH study received ethical approval from the Far North Queensland Human Research Ethics Committee, HREC/17/QCH/104–1174 and is registered on the Australian and New Zealand Trials Registry, ACTRN12617000198325p.

scholarly journals Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals

Nutrients ◽  
2021 ◽  
Vol 13 (8) ◽  
pp. 2635
Author(s):  
Koen Huysentruyt ◽  
Kim Brunet-Wood ◽  
Robert Bandsma ◽  
Leah Gramlich ◽  
Bonnie Fleming-Carroll ◽  
...  
Keyword(s):  
Health Care Professionals ◽  
Care Pathway ◽  
Clinical Care ◽  
Tertiary Care ◽  
Nationwide Survey ◽  
Nutritional Screening ◽  
Pediatric Hospitals ◽  
Adoption And Implementation ◽  
Clinical Care Pathway

Background: Disease-associated malnutrition (DAM) is common in hospitalized children. This survey aimed to assess current in-hospital practices for clinical care of pediatric DAM in Canada. Methods: An electronic survey was sent to all 15 tertiary pediatric hospitals in Canada and addressed all pillars of malnutrition care: screening, assessment, treatment, monitoring and follow-up. Results: Responses of 120 health care professionals were used from all 15 hospitals; 57.5% were medical doctors (MDs), 26.7% registered dietitians (RDs) and 15.8% nurses (RNs). An overarching protocol for prevention, detection and intervention of pediatric malnutrition was present or “a work in progress”, according to 9.6% of respondents. Routine nutritional screening on admission was sometimes or always performed, according to 58.8%, although the modality differed among hospitals and profession. For children with poor nutritional status, lack of nutritional follow-up after discharge was reported by 48.5%. Conclusions: The presence of a standardized protocol for the clinical assessment and management of DAM is uncommon in pediatric tertiary care hospitals in Canada. Routine nutritional screening upon admission has not been widely adopted. Moreover, ongoing nutritional care of malnourished children after discharge seems cumbersome. These findings call for the adoption and implementation of a uniform clinical care pathway for malnutrition among pediatric hospitals.

scholarly journals Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation

2021 ◽  
pp. bmjqs-2020-011593
Author(s):  
Traber D Giardina ◽  
Saritha Korukonda ◽  
Umber Shahid ◽  
Viralkumar Vaghani ◽  
Divvy K Upadhyay ◽  
...  
Keyword(s):  
Medical Record ◽  
Clinical Care ◽  
Diagnostic Testing ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Diagnostic Process ◽  
Healthcare Organisation ◽  
Safety Concerns ◽  
Patient Complaints ◽  
Malpractice Claims

BackgroundPatient complaints are associated with adverse events and malpractice claims but underused in patient safety improvement.ObjectiveTo systematically evaluate the use of patient complaint data to identify safety concerns related to diagnosis as an initial step to using this information to facilitate learning and improvement.MethodsWe reviewed patient complaints submitted to Geisinger, a large healthcare organisation in the USA, from August to December 2017 (cohort 1) and January to June 2018 (cohort 2). We selected complaints more likely to be associated with diagnostic concerns in Geisinger’s existing complaint taxonomy. Investigators reviewed all complaint summaries and identified cases as ‘concerning’ for diagnostic error using the National Academy of Medicine’s definition of diagnostic error. For all ‘concerning’ cases, a clinician-reviewer evaluated the associated investigation report and the patient’s medical record to identify any missed opportunities in making a correct or timely diagnosis. In cohort 2, we selected a 10% sample of ‘concerning’ cases to test this smaller pragmatic sample as a proof of concept for future organisational monitoring.ResultsIn cohort 1, we reviewed 1865 complaint summaries and identified 177 (9.5%) concerning reports. Review and analysis identified 39 diagnostic errors. Most were categorised as ‘Clinical Care issues’ (27, 69.2%), defined as concerns/questions related to the care that is provided by clinicians in any setting. In cohort 2, we reviewed 2423 patient complaint summaries and identified 310 (12.8%) concerning reports. The 10% sample (n=31 cases) contained five diagnostic errors. Qualitative analysis of cohort 1 cases identified concerns about return visits for persistent and/or worsening symptoms, interpersonal issues and diagnostic testing.ConclusionsAnalysis of patient complaint data and corresponding medical record review identifies patterns of failures in the diagnostic process reported by patients and families. Health systems could systematically analyse available data on patient complaints to monitor diagnostic safety concerns and identify opportunities for learning and improvement.

Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway

2021 ◽  
pp. 105566562110174
Author(s):  
Thomas R. Cawthorn ◽  
Anna R. Todd ◽  
Nina Hardcastle ◽  
Adam O. Spencer ◽  
A. Robertson Harrop ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Cleft Palate ◽  
Care Pathway ◽  
Clinical Care ◽  
Oral Intake ◽  
Opioid Consumption ◽  
Complication Rates ◽  
Cleft Palate Repair ◽  
Palate Repair ◽  
Clinical Care Pathway

Objective: To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair. Design: Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40). Patients: Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital. Interventions: A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized. Main Outcome Measures: Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively. Results: Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P < .001), decreased cumulative morphine consumption (77 vs 727 μg/kg, P < .001), shorter time to initiate oral intake (9.3 vs 22 hours, P = .01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P < .001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups. Conclusions: Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively.

scholarly journals Increase in recruitment upon integration of trial into a clinical care pathway: an observational study

2021 ◽  
Vol 8 (1) ◽  
pp. e000967
Author(s):  
Kay Por Yip ◽  
Simon Gompertz ◽  
Catherine Snelson ◽  
Jeremy Willson ◽  
Shyam Madathil ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Hospital Admissions ◽  
Care Pathway ◽  
Clinical Care ◽  
Intensive Therapy ◽  
Respiratory Support ◽  
Trial Recruitment ◽  
Recruitment Process ◽  
Support Unit ◽  
Clinical Care Pathway

IntroductionMany respiratory clinical trials fail to reach their recruitment target and this problem exacerbates existing funding issues. Integration of the clinical trial recruitment process into a clinical care pathway (CCP) may represent an effective way to significantly increase recruitment numbers.MethodsA respiratory support unit and a CCP for escalation of patients with severe COVID-19 were established on 11 January 2021. The recruitment process for the Randomised Evaluation of COVID-19 Therapy-Respiratory Support trial was integrated into the CCP on the same date. Recruitment data for the trial were collected before and after integration into the CCP.ResultsOn integration of the recruitment process into a CCP, there was a significant increase in recruitment numbers. Fifty patients were recruited over 266 days before this process occurred whereas 108 patients were recruited over 49 days after this process. There was a statistically significant increase in both the proportion of recruited patients relative to the number of COVID-19 hospital admissions (change from 2.8% to 9.1%, p<0.0001) and intensive therapy unit admissions (change from 17.8% to 50.2%, p<0.001) over the same period, showing that this increase in recruitment was independent of COVID-19 prevalence.DiscussionIntegrating the trial recruitment process into a CCP can significantly boost recruitment numbers. This represents an innovative model that can be used to maximise recruitment without impacting on the financial and labour costs associated with the running of a respiratory clinical trial.

The Mount Sinai (New York) Visiting Doctors Program: Meeting the Needs of the Urban Homebound Population

2011 ◽  
Vol 12 (4) ◽  
pp. 139-143 ◽  
Author(s):  
Katherine Ornstein ◽  
Cameron R. Hernandez ◽  
Linda V. DeCherrie ◽  
Theresa A. Soriano
Keyword(s):  
New York ◽  
Social Work ◽  
Clinical Care ◽  
Older Individuals ◽  
Social Service Agencies ◽  
Complex Needs ◽  
Home Based ◽  
Major Teaching ◽  
Mount Sinai ◽  
Physician Availability

The Mount Sinai Visiting Doctors program, a joint program of Mount Sinai Medical Center’s Departments of Medicine and Geriatrics, is a large multidisciplinary teaching, research, and clinical care initiative serving homebound adults in Manhattan since 1995. Caring for more than 1,000 patients annually, the physicians of Visiting Doctors make more than 6,000 urgent and routine visits each year, making it the largest program of its kind in the country. Services include 24–hour physician availability, palliative care, social work case management, collaboration with nursing agencies, and in-home specialty consultation. The program serves many individuals who have previously received inadequate and inconsistent medical care. Patients are referred by social service agencies, local physicians, and hospitals and are primarily frail older individuals with complex needs. Funded by Mount Sinai and private support, the program serves as a major teaching site for medical, nursing, and social work trainees interested in home-based primary care.

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