A qualitative study of patient involvement in medicines management after hospital discharge: an under-recognised source of systems resilience

IntroductionThere are risks to the safety of medicines management when patient care is transferred between healthcare organisations, for example, when a patient is discharged from hospital. Using the theoretical concept of resilience in healthcare, this study aimed to better understand the proactive role that patients can play in creating safer, resilient medicines management at a common transition of care.MethodsQualitative interviews with 60 cardiology patients 6 weeks after their discharge from 2 UK hospitals explored patients’ experiences with their discharge medicines. Data were initially subjected to an inductive thematic analysis and a subsequent theory-guided deductive analysis.ResultsDuring interviews 23 patients described medicines management resilience strategies in two main themes: identifying system vulnerabilities; and establishing self-management strategies. Patients could anticipate problems in the system that supplied them with medicines and took specific actions to prevent them. They also identified when errors had occurred both before and after medicines had been supplied and took corrective action to avoid harm. Some reported how they had not foreseen problems or experienced patient safety incidents. Patients recounted how they ensured information about medicines changes was correctly communicated and acted upon, and described their strategies to enhance their own reliability in adherence and resource management.ConclusionPatients experience the impact of vulnerabilities in the medicines management system across the secondary–primary care transition but many are able to enhance system resilience through developing strategies to reduce the risk of medicines errors occurring. Consequently, there are opportunities—with caveats—to elicit, develop and formalise patients’ capabilities which would contribute to safer patient care and more effective medicines management.

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Manejo da dor em punção venosa pediátrica: um pacote de medidas

Revista Recien - Revista Científica de Enfermagem ◽

10.24276/rrecien2021.11.33.157-168 ◽

2021 ◽

Vol 11 (33) ◽

pp. 157-168

Author(s):

Larissa Grispan e Silva Guimarães ◽

Natália Shinkai Binotto ◽

Stela Faccioli Ederli ◽

Mauren Teresa Grubisich Mendes Tacla

Keyword(s):

Pain Management ◽

Patient Care ◽

Nursing Staff ◽

Professional Growth ◽

Management Strategies ◽

Care Bundle ◽

Evidence Based ◽

Topical Anesthetic ◽

Care Research ◽

Before And After

Apresentar o processo de elaboração de um pacote de medidas para manejo da dor de crianças submetidas à punção venosa pela equipe de enfermagem. Pesquisa Convergente Assistencial, do tipo antes e após intervenção, realizada com a equipe de enfermagem de uma unidade pediátrica do sul do Brasil. Elaboração de pacote de medidas com seis estratégias selecionadas pela equipe de enfermagem a serem utilizadas antes e durante a punção venosa: preparo da criança e/ou acompanhante, posicionamento da criança, distração, amamentação, solução adocicada associada ou não à sucção não nutritiva e anestésico tópico. Os participantes manifestaram satisfação quanto ao modo de elaboração do mesmo, destacando a contribuição deste para seu crescimento profissional. O pacote de medidas otimizou a adoção das estratégias para manejo da dor. A Pesquisa Convergente Assistencial alicerçada na prática baseada em evidências mostrou-se adequada, visto que propiciou a aplicação de achados científicos no cenário assistencial considerando suas particularidades.Descritores: Manejo da Dor, Criança, Cateterismo Periférico, Enfermagem Baseada em Evidências. Management of pediatric venipuncture pain: a package of measuresAbstract: To present the process of elaboration of a patient care package for pain management in children undergoing venipuncture by the nursing staff. Convergent Care Research, before and after intervention, conducted with the nursing staff of a southern pediatric unit in Brazil. Patient care packege with six strategies, selected by the nursing staff, to be used before and during venipuncture: preparation of the child and/or companion, child positioning, distraction, breastfeeding, sweet-tasting solution with or without non-nutritive suction and topical anesthetic usage. The package of measures optimized the adoption of pain management strategies, highlighting its contribution to their professional growth. The patient care bundle optimized the adoption of strategies for pain management. The Convergent Care Research grounded in evidence-based practice showed appropriate, since it allowed the application of scientific findings in the care setting, considering its peculiarities.Descriptors: Pain Management, Child, Catheterization, Peripheral, Evidence-Based Nursing. Manejo del dolor de la venopunción pediátrica: un paquete de medidasResumen: Presentar el proceso de elaboración de un paquete de medidas para manejo del dolor de niños sometidos a la venopunción por el equipo de enfermería. Investigación Convergente Asistencial, del tipo antes y después de la intervención, realizada con el equipo de enfermería de una unidad pediátrica en el sur de Brasil. Paquete de medidas con seis estrategias seleccionadas por el equipo de enfermería que deben ser utilizadas antes y durante la venopunción: preparación del niño y/o acompañante, posicionamiento del niño, distracción, amamantamiento, solución dulce asociada o no a succión no nutritiva y anestésica tópica. Los participantes manifestaron satisfacción en cuanto al modo de elaboración del mismo, destacando la contribución de este para su crecimiento profesional. El paquete de medidas optimizó la adopción de estrategias para manejo del dolor. La Investigación Convergente Asistencial cimentada en la práctica basada en evidencias se mostró adecuada, visto que propició la aplicación de hallazgos científicos en el escenario asistencial considerando sus particularidades.Descriptores: Manejo del Dolor, Niño, Cateterismo Periférico, Enfermería Basada en la Evidencia.

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Creation and implementation of a novel clinical workflow based on the AAST uniform anatomic severity grading system for emergency general surgery conditions

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000552 ◽

2020 ◽

Vol 5 (1) ◽

pp. e000552 ◽

Cited By ~ 1

Author(s):

Kovi E Bessoff ◽

Jeff Choi ◽

Sylvia Bereknyei Merrell ◽

Aussama Khalaf Nassar ◽

David Spain ◽

...

Keyword(s):

Patient Care ◽

General Surgery ◽

Qualitative Interviews ◽

Grading System ◽

Clinical Workflow ◽

Emergency General Surgery ◽

Level Of Evidence ◽

Severity Scores ◽

Severity Grading ◽

The Impact

ObjectiveEmergency general surgery (EGS) conditions encompass a variety of diseases treated by acute care surgeons. The heterogeneity of these diseases limits infrastructure to facilitate EGS-specific quality improvement (QI) and research. A uniform anatomic severity grading system for EGS conditions was recently developed to fill this need. We integrated this system into our clinical workflow and examined its impact on research, surgical training, communication, and patient care.MethodsThe grading system was integrated into our clinical workflow in a phased fashion through formal education and a written handbook. A documentation template was also deployed in our electronic medical record to prospectively assign severity scores at the time of patient evaluation. Mixed methods including a quantitative survey and qualitative interviews of trainees and attending surgeons were used to evaluate the impact of the new workflow and to identify obstacles to its adoption.ResultsWe identified 2291 patients presenting with EGS conditions during our study period. The most common diagnoses were small bowel obstruction (n=470, 20.5%), acute cholecystitis (n=384, 16.8%), and appendicitis (n=370, 16.1%). A total of 21 qualitative interviews were conducted. Twenty interviewees (95.2%) had a positive impression of the clinical workflow, citing enhanced patient care and research opportunities. Fifteen interviewees (75.0%) reported the severity grading system was a useful framework for clinical management, with five participants (25.0%) indicating the system was useful to facilitate clinical communication. Participants identified solutions to overcome barriers to adoption of the clinical workflow.ConclusionsThe uniform anatomic severity grading system can be readily integrated into a clinical workflow to facilitate prospective data collection for QI and research. The system is perceived as valuable by users. Educational initiatives that focus on increasing familiarity with the system and its benefits will likely improve adoption of the classification system and the clinical workflow that uses it.Level of evidenceLevel III.

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The Impact of Visualization Dashboards on Patient Care in the Emergency Room (Preprint)

10.2196/preprints.18423 ◽

2020 ◽

Author(s):

Doaa Alhabib ◽

Arwa Alumran ◽

Saja Alrayes

Keyword(s):

Emergency Room ◽

Patient Care ◽

Cross Sectional Study ◽

Royal Commission ◽

Quality And Safety ◽

Cross Sectional ◽

Future Studies ◽

Before And After ◽

Artery Disease ◽

The Impact

UNSTRUCTURED Displaying patients’ data on electronic dashboards in the emergency room provides emergency room employees continuous visual monitoring. With this study, we aimed to measure the effects of displaying data on electronic dashboards on the quality and safety of the patient care provided in the emergency room (ER). We used a cross-sectional study design to compare the results of specific quality and safety indicators before and after the implementation of the dashboards in the ER of the Royal Commission Hospital, Jubail, Saudi Arabia. Our results showed statistically significant improvements on the waiting time for all ER patients, the total length of stay in the ER, and the time from arrival until an electrocardiogram test was performed for patients who came to the ER with symptoms suggesting coronary artery disease. Future studies might be conducted to evaluate the end-users’ utilization and satisfaction of the ER dashboards.

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Implementation of Computerized Provider Order Entry (CPOE) Does Not Impact Provider Work Time in An Inpatient Malignant Hematology Service

Blood ◽

10.1182/blood.v112.11.4704.4704 ◽

2008 ◽

Vol 112 (11) ◽

pp. 4704-4704

Author(s):

David A Hanauer ◽

Sung W Choi ◽

Robert W Beasley ◽

Ronald B Hirschl ◽

Douglas W Blayney

Keyword(s):

Patient Care ◽

Training Session ◽

Direct Patient Care ◽

Order Entry ◽

Time And Motion Study ◽

Time And Motion ◽

Motion Study ◽

Order Sets ◽

Before And After ◽

The Impact

Abstract No data are available concerning the impact of CPOE on inpatient leukemia and lymphoma care. CPOE may improve patient safety, reduce time between order entry and medication administration, and reduce medication and transcription errors. However, concerns have arisen about potential increased time required to enter electronic orders compared to handwritten orders. Our hypothesis was that CPOE would require more order-related time from caregivers, and reduce the amount of time for direct patient care. We studied the work patterns of three Physician Assistants (PAs) who worked under the supervision of faculty physicians, and were the exclusive inpatient care providers. The PA-staffed hematology service was chosen to minimize the impact of rotating house staff on our results. Faculty, who were not studied, entered the few chemotherapy orders necessary, while PAs entered orders for hydration, antibiotics, supportive care and other medications, and for consultations and diagnostic tests. The UMHS Institutional Review Board reviewed the study protocol and waived the requirement for patient informed consent. We performed a direct observation time and motion study pre- and post-implementation of a commercial CPOE system (Sunrise Clinical Manager™ 4.5, Eclipsys, Boca Raton, Florida) on one inpatient hematology service at the UMHS University Hospital. The same three PAs were shadowed pre- and post-implementation. We also closely matched morning and afternoon observation times in order to reduce variability in activities taking place at different times of the day. Prior to CPOE implementation the PAs had a 4 hour general training session and a 1 hour chemotherapy training session. Pre-built order sets were routinely used by the PAs. A portable tablet computer was used by an independent observer to record data, using a data entry interface containing 63 individual activity categories modified from the Time and Motion database under “IT Tools” at http://www.ahrq.gov. Data were grouped into subcategories for analysis. We grouped 12 activities as ordering-related (e.g. writing orders, writing forms, clarifying orders, etc.) We observed the same three PAs for 85.4 hours (over 2 weeks) pre, and for 75.8 hours (over 4 weeks) starting 3 months post-CPOE. Mean patient census was 11.3 per day pre- and 9.2 per day post implementation observation periods. Overall time for order-related activities was unchanged, requiring 7.7% of total time pre- and 8.1% of total time post-CPOE even though actual order writing took longer with CPOE compared to written (4.9% pre vs. 7.0% post). CPOE had almost no impact on direct patient care time (Figure), with PAs spending 38.2% total time on direct patient care pre-CPOE compared to 38.4% post. A minimal difference was also found with the overall total for indirect patient care activities (37.1% pre vs. 38.7% post). Our results suggest that using CPOE on a busy hematology inpatient service has minimal impact on time spent by trained PAs using standard order sets 3 months after implementation. The decision to adopt CPOE for a busy hematology service should not be based on the hypothesis that there will be a change in workflow or task organization. More study is needed to determine if CPOE for hematology patients results in a change in the quality of patient care or safety. Figure. Percentage of total time spent in 6 analysis categories both before and after implementation of a commercial CPOE system for an inpatient hematology service. These 6 categories represent 63 individual activities categories that were recorded in the time and motion study. Error bars represent 95% confidence intervals. Figure. Percentage of total time spent in 6 analysis categories both before and after implementation of a commercial CPOE system for an inpatient hematology service. These 6 categories represent 63 individual activities categories that were recorded in the time and motion study. Error bars represent 95% confidence intervals.

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Impacts of land management on the resilience of Mediterranean dry forests to fire

10.20944/preprints201607.0081.v1 ◽

2016 ◽

Author(s):

Matteo Jucker Riva ◽

Gudrun Schwilch ◽

Hanspeter Liniger ◽

Alejandro Valdecantos

Keyword(s):

Land Management ◽

Management Practices ◽

Fire Regime ◽

Management Strategies ◽

Time Frame ◽

Mediterranean Forests ◽

Before And After ◽

History Of ◽

Time Specific ◽

The Impact

Wildfires have always been a part of the history of Mediterranean forests. However, forest regeneration after a wildfire is not certain. It depends on many factors, some of which may be influenced by land management activities. Failure of regeneration will cause a regime shift in the ecosystem, reducing the provision of ecosystem services and ultimately leading to desertification. How can we increase Mediterranean forests’ resilience to fire? To answer this question, we did a literature review, investigating chains of processes that allow forests to regenerate (which we label “regeneration mechanisms”), and assessed the impact of selected management practices documented in the WOCAT database on the regeneration mechanisms. We identified three distinct regeneration mechanisms that enable Mediterranean forests to recover, as well as the time frame before and after a fire in which they are at work, and factors that can hinder or support resilience. The three regeneration mechanisms enabling a forest to regenerate after a fire consist of regeneration (1) from a seed bank; (2) from resprouting individuals; and (3) from unburned plants that escaped the fire. Management practices were grouped into four categories: (1) fuel breaks, (2) fuel management, (3) afforestation, and (4) mulching. We assessed how and under what conditions land management modifies the ecosystem’s resilience. The results show that land management influences resilience by interacting with resilience mechanisms before and after the fire, and not just by modifying the fire regime. Our analysis demonstrates a need for adaptive – i.e. context- and time-specific – management strategies.

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REVITALIZING HISTORIC AREAS; LESSONS FROM THE RENOVATION OF SAIDPUR VILLAGE, ISLAMABAD

Journal of Research in Architecture and Planning ◽

10.53700/jrap1812015_2 ◽

2015 ◽

Vol 18 (1) ◽

pp. 11-22

Author(s):

Samra M. Khan

Keyword(s):

Local Community ◽

Solid Waste Management ◽

Qualitative Interviews ◽

Historic Districts ◽

Before And After ◽

Historic Areas ◽

Heritage Buildings ◽

Historical Architecture ◽

The Impact ◽

The Village

Over the past decades, traditional cities and their historic districts have been deteriorating steadily. The combination of modernity, congestion, old infrastructure and financial pressures have led to migration of people from old neighborhoods and their eventual decline and decay. In league with this loss of traditional cities, in Islamabad, the Central Development Authority (CDA) decided to revitalize the historic village of Saidpur. The project undertook to restore historical architecture, encourage tourism and reverse the cycle of decay by economic and social revival of the area. Saidpur is a small historic village, possibly 500 years old, located at the base of the Margalla Hills. The center of the village has old heritage buildings in the form of two mandirs (temple) and a dharamshala (sanctuary). These were neglected and undergoing rapid deterioration. The infrastructure of the area was underdeveloped, with open drains, unpaved pathways and no solid waste management system. This paper studies the process and results of this revitalization project analysing the impact of the project on the cultural, social and economic conditions of the village. The methodology of this study was based on qualitative interviews with the residents of the village, CDA officials and direct observation of the spaces (before and after renovation). The paper concludes that the local community must be the engine of any sustainable revitalization of cultural heritage. In the case of Saidpur Village, gentrification without community participation has threatened the social and historic cohesion of the area, leading to brutal transformation and marginalization of local residents. Keywords: Saidpur, renovation, sustainable revitalization, heritage, community.

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LO56: Novel role of physician navigators on performance indicators in the emergency department

CJEM ◽

10.1017/cem.2017.118 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S47

Author(s):

A. Leung ◽

G. Puri ◽

B. Chen ◽

Z. Gong ◽

E. Chan ◽

...

Keyword(s):

Emergency Department ◽

Patient Care ◽

Mixed Linear Model ◽

Primary Objective ◽

Initial Assessment ◽

Direct Patient Care ◽

Healthcare Team ◽

Left Without Being Seen ◽

Before And After ◽

The Impact

Introduction: Burnout rates for emergency physicians (EP) continue to be amongst the highest in medicine. One of the commonly cited sources of stress contributing to disillusionment is bureaucratic tasks that distract EPs from direct patient care in the emergency department (ED). The novel position of Physician Navigator was created to help EPs decrease their non-clinical workload during shifts, and improve productivity. Physician Navigators are non-licensed healthcare team members that assist in activities which are often clerical in nature, but directly impact patient care. This program was implemented at no net-cost to the hospital or healthcare system. Methods: In this retrospective study, 6845 clinical shifts worked by 20 EPs over 39 months from January 1, 2012 to March 31, 2015 were evaluated. The program was implemented on April 1, 2013. The primary objective was to quantify the effect of Physician Navigators on measures of EP productivity: patient seen per hour (Pt/hr), and turn-around-time (TAT) to discharge. Secondary objectives included examining the impact of Physician Navigators on measures of ED throughput for non-resuscitative patients: emergency department length of stay (LOS), physician-initial-assessment times (PIA), and left-without-being-seen rates (LWBS). A mixed linear model was used to evaluate changes in productivity measures between shifts with and without Physician Navigators in a clustered design, by EP. Autoregressive modelling was performed to compare ED throughput metrics before and after the implementation of Physician Navigators for non-resuscitative patients. Results: Across 20 EPs, 2469 shifts before, and 4376 shifts after April 1, 2013 were analyzed. Daily patient volumes increased 8.7% during the period with Physician Navigators. For the EPs who used Physician Navigators, Pt/hr increased by 1.07 patients per hour (0.98 to 1.16, p<0.001), and TAT to discharge decreased by 10.6 minutes (-13.2 to -8.0, p<0.001). After the implementation of the Physician Navigators, overall LOS for non-resuscitative patients decreased by 2.6 minutes (1.0%, p=0.007), and average PIA decreased by 7.4 minutes (12.0%, p<0.001). LBWS rates decreased by 43.9% (0.50% of daily patient volume, p<0.001). Conclusion: The use of a Physician Navigator was associated with increased EP productivity as measured by Pt/hr, and TAT to discharge, and reductions in ED throughput metrics for non-resuscitative patients.

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Dietitians can improve accuracy of prescribing by interacting with electronic prescribing systems

BMJ Health & Care Informatics ◽

10.1136/bmjhci-2019-000019 ◽

2019 ◽

Vol 26 (1) ◽

pp. e000019 ◽

Cited By ~ 2

Author(s):

Susan De Waal ◽

Laurie Lucas ◽

Simon Ball ◽

Tanya Pankhurst

Keyword(s):

Electronic Health Records ◽

Patient Care ◽

Multidisciplinary Team ◽

Electronic Prescribing ◽

Health Records ◽

Improve Accuracy ◽

Before And After ◽

Improving Accuracy ◽

The Impact ◽

To Receive

BackgroundDietitians increasingly interact with electronic health records (EHRs) and use them to alert prescribers to medication inaccuracies.ObjectiveTo understand renal dietitians’ use of electronic prescribing systems and influence on medication accuracy in inpatients. In outpatients to determine whether renal dietitians’ use of the electronic medication recording might improve accuracy.MethodsIn inpatients we studied the impact of dietetic advice on medical prescribing before and after moving from paper recommendations to ePrescribing. In outpatients, when dietitians recommended changes in dialysis units, we assessed the time to patients receiving the new medications. We trained dietitians to use the ePrescribing system and assessed accuracy of medication lists at the start and end of the study period.ResultsInpatients: before the use of EHRs, 25% of proposals were carried out and took an average of 20 days. This rose to 38% using an EHR and took an average of 4 days.Outpatients: in dialysis units dietitians recommend initiating and stopping medications and advise on repeat medications. Most recommendations were during multidisciplinary team (MDT) meetings; the average time to receive medications was 10 days. Drug histories updated by dietitians increased after the start of the study and accuracy of medication lists improved from 2.4 discrepancies/patient to 0.4.ConclusionDietitians can make medication suggestions directly using EHR, delivering more timely change to patient care and improving accuracy of patients’ medication lists. Allowing the whole of the MDT to contribute to the EHR improves data completeness and therefore patient care is likely to be enhanced.

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Girl Champ in eSwatini: A Strategic Marketing Campaign to Promote Demand for Sexual and Reproductive Health Services Among Young Women

AIDS and Behavior ◽

10.1007/s10461-021-03446-y ◽

2021 ◽

Author(s):

Marie A. Brault ◽

Sarah Christie ◽

Amanda Manchia ◽

Khabonina Mabuza ◽

Muhle Dlamini ◽

...

Keyword(s):

Young Women ◽

Qualitative Interviews ◽

Strategic Marketing ◽

Reproductive Health Services ◽

Hiv Services ◽

Mixed Methods Evaluation ◽

Demand Creation ◽

Before And After ◽

Reproductive Services ◽

The Impact

AbstractEfforts to engage adolescent girls and young women (AGYW) in HIV services have struggled, in part, due to limited awareness of services and stigma. Strategic marketing is a promising approach, but the impact on youth behavior change is unclear. We report findings from a mixed methods evaluation of the Girl Champ campaign, designed to generate demand for sexual and reproductive services among AGYW, and piloted in three clinics in the Manzini region of eSwatini. We analyzed and integrated data from longitudinal, clinic-level databases on health service utilization among AGYW before and after the pilot, qualitative interviews with stakeholders responsible for the implementation of the pilot, and participant feedback surveys from attendees of Girl Champ events. Girl Champ was well received by most stakeholders based on event attendance and participant feedback, and associated with longitudinal improvements in demand for HIV services. Findings can inform future HIV demand creation interventions for youth.

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Impact of a Parent-Directed Pamphlet About Pain Management During Infant Vaccinations on Maternal Knowledge and Behavior

Neonatal Network The Journal of Neonatal Nursing ◽

10.1891/0730-0832.33.2.74 ◽

2014 ◽

Vol 33 (2) ◽

pp. 74-82 ◽

Cited By ~ 8

Author(s):

Anna Taddio ◽

Noni E. MacDonald ◽

Sarah Smart ◽

Chaitya Parikh ◽

Victoria Allen ◽

...

Keyword(s):

Pain Management ◽

Management Strategies ◽

Maternal Knowledge ◽

Intervention Site ◽

Management Interventions ◽

Before And After ◽

And Behavior ◽

The Impact ◽

Routine Infant ◽

Before And After Study

Purpose: To evaluate the impact of a parent-directed instructional pamphlet about managing pain during infant vaccinations.Design and Sample: New mothers hospitalized following birth of an infant at two hospitals participated in a “before-and-after” study. In the “after” phase, the pamphlet was passively inserted in discharge packages at the intervention hospital.Main Outcomes: Maternal knowledge and self-reported use of pain-management interventions during routine infant two-month vaccinations.Results: Altogether, 354 mothers participated. A two-way (site, phase) ANOVA revealed no interaction (site × phase) in knowledge or use of pain-management strategies after routine two-month infant vaccinations; hence, there was no evidence of a benefit provided by the pamphlet. However, within the intervention site, only 21 percent of mothers read the pamphlet. Reading the pamphlet was associated with higher knowledge. This suggests some possible benefits of the pamphlet, provided that mothers read it.

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