Implementing emergency admission risk prediction in general practice: a qualitative study

2021 ◽  
pp. BJGP.2021.0146
Author(s):  
Bridie Angela Evans ◽  
Jeremy Dale ◽  
Jan Davies ◽  
Hayley Hutchings ◽  
Mark Rhys Kingston ◽  
...  
Keyword(s):  
General Practice ◽  
Risk Stratification ◽  
Patient Care ◽  
Normalisation Process Theory ◽  
Small Scale ◽  
Routine Practice ◽  
Emergency Hospital ◽  
Number Of Patients ◽  
Short Period ◽  
Predictive Risk

Background: Using computer software in general practice to predict patient risk of emergency hospital admission has been widely advocated despite limited evidence about effects. In a trial evaluating introduction of a predictive risk stratification model (PRISM), we reported statistically significant increases in emergency hospital admissions and use of other NHS services without evidence of benefits to patients or the NHS. Aim: to explore experiences of incorporating PRISM into routine practice. Design and setting: semi-structured interviews with 22 general practitioners and practice managers in 18 practices in South Wales. Methods: Interviews at two timepoints: 3-6 months after gaining PRISM access; study end, approximately 18 months later. We analysed data thematically using Normalisation Process Theory. Results: Respondents reported the decision to use PRISM was based mainly on fulfilling reporting requirements for Quality and Outcome Framework (QOF) incentives. Most applied it to a very small number of patients for a short period. Using PRISM entailed technical tasks, information sharing within practice meetings and small-scale changes to patient care. Use was inhibited by PRISM not being integrated with practice systems. Most doubted any large scale impact, but cited examples of impact on individual patient care. They reported increased awareness of patients in high-risk groups. Conclusions: Qualitative results suggest mixed views of predictive risk stratification in general practice and raised awareness of highest-risk patient groups, potentially affecting unplanned hospital attendance and admissions. To inform future policy, decision-makers need more information about implementation and effects of emergency admissions risk stratification tools in primary and community settings.

scholarly journals Implementation of predictive risk stratification to reduce emergency admissions to hospital: experiences of general practitioners and practice managers

2021 ◽  
Author(s):  
Bridie Angela Evans ◽  
Jan Davies ◽  
Jeremy Dale ◽  
Hayley Hutchings ◽  
Mark Kingston ◽  
...  
Keyword(s):  
Primary Care ◽  
Risk Stratification ◽  
Patient Care ◽  
General Practitioners ◽  
Normalisation Process Theory ◽  
Small Scale ◽  
Emergency Admissions ◽  
Number Of Patients ◽  
Short Period ◽  
Predictive Risk

AbstractAimIn a trial evaluating the introduction of a predictive risk stratification model (PRISM) into primary care, we reported statistically significant increases in emergency hospital admissions and use of other NHS services without evidence of benefits to patients or the NHS. The aim of this study was to explore the views and experiences of general practitioners (GPs) and practice managers on incorporating PRISM into routine practice.MethodsWe interviewed 22 GPs and practice managers in 18 participating practices at two timepoints: 3-6 months after PRISM was available in their practice; and at study end, up to 18 months later. We recorded and transcribed interviews and analysed data thematically using Normalisation Process Theory.ResultsRespondents reported that the decision to use PRISM was based mainly on fulfilling reporting requirements for Quality and Outcome Framework (QOF) incentives. Most applied it to a very small number of patients for a short period. Using PRISM entailed technical tasks, information sharing within practice meetings and changes to patient care. These were diverse and generally small scale. Use was inhibited by PRISM not being integrated with practice systems. Respondents’ evaluation of PRISM was mixed: most doubted it had any large scale impact, but many cited examples of impact on individual patient care. They reported increased awareness of patients in high risk groups.ConclusionsQualitative results suggest mixed views of predictive risk stratification in primary care and raised awareness of highest-risk patient groups, potentially affecting unplanned hospital attendance and admissions. To inform future policy, decision-makers need more information about implementation and effects of emergency admissions risk stratification tools in primary and community settings.Trial registrationControlled Clinical Trials no. ISRCTN55538212.

Enhancing hospital care of patients with cognitive impairment

2018 ◽  
Vol 31 (2) ◽  
pp. 173-186 ◽  
Author(s):  
Loretta M. Isaac ◽  
Elaine Buggy ◽  
Anita Sharma ◽  
Athena Karberis ◽  
Kim M. Maddock ◽  
...  
Keyword(s):  
Cognitive Impairment ◽  
Patient Care ◽  
Positive Impact ◽  
Healthcare Delivery ◽  
Improve Patient Care ◽  
Health Care Facilities ◽  
Small Scale ◽  
Content Type ◽  
Loved One ◽  
Number Of Patients

Purpose The patient-centred management of people with cognitive impairment admitted to acute health care facilities can be challenging. The TOP5 intervention utilises carers’ expert biographical and social knowledge of the patient to facilitate personalised care. The purpose of this paper is to explore whether involvement of carers in the TOP5 initiative could improve patient care and healthcare delivery. Design/methodology/approach A small-scale longitudinal study was undertaken in two wards of one acute teaching hospital. The wards admitted patients with cognitive impairment, aged 70 years and over, under geriatrician care. Data for patient falls, allocation of one-on-one nurses (“specials”), and length-of-stay (LOS) over 38 months, including baseline, pilot, and establishment phases, were analysed. Surveys of carers and nursing staff were undertaken. Findings There was a significant reduction in number of falls and number of patients allocated “specials” over the study period, but no statistically significant reduction in LOS. A downward trend in complaints related to communication issues was identified. All carers (n=43) completing the feedback survey were satisfied or very satisfied that staff supported their role as information provider. Most carers (90 per cent) felt that the initiative had a positive impact and 80 per cent felt that their loved one benefitted. Six months after implementation of the initiative, 80 per cent of nurses agreed or strongly agreed that it was now easier to relate to carers of patients with cognitive impairment. At nine-ten months, this increased to 100 per cent. Originality/value Actively engaging carers in management of people with cognitive impairment may improve the patient, staff, and carer journeys, and may improve outcomes for patient care and service delivery.

Effects and costs of predictive risk stratification in primary care: randomised stepped wedge trial

2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X696941
Author(s):  
Ian Russell ◽  
Kerry Bailey-Jones ◽  
Deborah Burge-Jones ◽  
Jeremy Dale ◽  
Bernadette Diethart ◽  
...  
Keyword(s):  
Primary Care ◽  
Risk Stratification ◽  
Hospital Admissions ◽  
Emergency Admission ◽  
Routine Data ◽  
Stepped Wedge ◽  
Emergency Hospital ◽  
Emergency Hospital Admissions ◽  
Patient Reported ◽  
Predictive Risk

BackgroundThe ageing UK population needs safe approaches to reduce emergency hospital admissions. Predictive risk stratification modelling (PRiSM) estimates risk that individuals will suffer emergency admission to hospital within 12 months and selects patients for preventative community care to avoid admissions.AimTo evaluate the introduction of (PRiSM) into primary care.MethodFunded by NIHR, we used randomised stepped wedge design to estimate (cost) effectiveness of introducing PRiSM software into 32 participating practices in urban South Wales, supported by practice-based training, clinical support through two local ‘GP champions’, and technical support through telephone help-desk. Outcome measures included: emergency hospital admissions (primary), other hospital activity, and GP activity, all estimated from routine data; patient-reported SF-12 health-related quality of life scores; and NHS costs.ResultsAcross 230,000 participants, PRiSM implementation increased: emergency hospital admission rates by 1.1% (95% confidence interval [CI] = 1.0% to 1.3%); Emergency Department attendance rates by 3.0% (95%CI = 2.8% to 3.2%); outpatient visit rates by 5.5% (95%CI = 5.1% to 5.8%); GP activity by 1.1% (95% CI = 0.7% to 1.4%); and NHS costs per patient by £76 (95%CI = £46 to £106). Questionnaires completed by 1400 randomly sampled participants showed that: PRISM improved SF-12 physical scores by 1.5 points (95%CI = 0.8 to 2.2); but not SF-12 mental scores (95%CI = −1.5 points to +0.3). The direct cost of introducing PRiSM was £0.11/patient/year.ConclusionThe introduction of PRiSM increased emergency hospital admissions and other NHS activity without clear evidence of benefit.

scholarly journals Implementation of remote asthma consulting in general practice in response to the COVID19 pandemic: evaluation using extended normalisation process theory

BJGP Open ◽  
2021 ◽  
pp. BJGPO.2021.0189
Author(s):  
Jonathan Stewart ◽  
Noleen McCorry ◽  
Helen Reid ◽  
Nigel Hart ◽  
Frank Kee
Keyword(s):  
General Practice ◽  
Healthcare System ◽  
Healthcare Professionals ◽  
Complex Interventions ◽  
Process Theory ◽  
Normalisation Process Theory ◽  
Routine Practice ◽  
Asthma Care ◽  
Practice Staff ◽  
Willingness To Use

BackgroundThe COVID-19 pandemic has led to the rapid and reactive deployment of remote consulting in UK General Practice. The delivery of acute and chronic asthma care has been affected. Extended Normalisation Process Theory (eNPT) provides a framework for evaluating the implementation of new complex interventions in routine practice, including examination of how context-intervention interactions affect Implementation.AimTo explore the implementation of remote asthma consulting in UK General Practice in response to the COVID-19 pandemic.Design & settingMixed methods evaluation, informed by eNPT.SettingGeneral Practice in Northern Ireland.MethodData was collected from a range of healthcare professionals who provide asthma care using online questionnaires, interviews and multidisciplinary focus groups. Analysis was informed by eNPT.ResultsWe identified ten themes to describe and explain the contribution of General Practice staff to implementation of remote asthma consulting. Staff identified novel alternatives to in-person review. Having a practice champion to drive implementation forward, and engage other Practice staff, was important. Patient, staff and healthcare system contextual factors influencing implementation were identified including access to, understanding of and willingness to use the technology required for remote consulting.ConclusionThe experiences of frontline healthcare professionals in this study indicate that remote asthma consulting has potential benefits in terms of access and effectiveness when implementation integrates seamlessly with face-to-face care for those who want or need it. Work is required at Practice and healthcare system levels to realise this potential, and ensure implementation does not exacerbate existing healthcare inequalities.

OP75 Implementing Risk Stratification In Primary Care: A Qualitative Study

2017 ◽  
Vol 33 (S1) ◽  
pp. 34-35
Author(s):  
Alison Porter ◽  
Helen Snooks ◽  
Mark Kingston ◽  
Jan Davies ◽  
Hayley Hutchings ◽  
...  
Keyword(s):  
Primary Care ◽  
Qualitative Study ◽  
Risk Stratification ◽  
Hospital Admission ◽  
Positive Impact ◽  
Normalisation Process Theory ◽  
Family Doctors ◽  
Emergency Hospital ◽  
Emergency Hospital Admission ◽  
Risk Patients

INTRODUCTION:A predictive risk stratification tool (PRISM) to estimate a patient's risk of an emergency hospital admission in the following year was trialled in general practice in an area of the United Kingdom. PRISM's introduction coincided with a new incentive payment (‘QOF’) in the regional contract for family doctors to identify and manage the care of people at high risk of emergency hospital admission.METHODS:Alongside the trial, we carried out a complementary qualitative study of processes of change associated with PRISM's implementation. We aimed to describe how PRISM was understood, communicated, adopted, and used by practitioners, managers, local commissioners and policy makers. We gathered data through focus groups, interviews and questionnaires at three time points (baseline, mid-trial and end-trial). We analyzed data thematically, informed by Normalisation Process Theory (1).RESULTS:All groups showed high awareness of PRISM, but raised concerns about whether it could identify patients not yet known, and about whether there were sufficient community-based services to respond to care needs identified. All practices reported using PRISM to fulfil their QOF targets, but after the QOF reporting period ended, only two practices continued to use it. Family doctors said PRISM changed their awareness of patients and focused them on targeting the highest-risk patients, though they were uncertain about the potential for positive impact on this group.CONCLUSIONS:Though external factors supported its uptake in the short term, with a focus on the highest risk patients, PRISM did not become a sustained part of normal practice for primary care practitioners.

scholarly journals Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trial

2018 ◽  
Vol 28 (9) ◽  
pp. 697-705 ◽  
Author(s):  
Helen Snooks ◽  
Kerry Bailey-Jones ◽  
Deborah Burge-Jones ◽  
Jeremy Dale ◽  
Jan Davies ◽  
...  
Keyword(s):  
Primary Care ◽  
Risk Stratification ◽  
Hospital Admissions ◽  
Health Board ◽  
Stepped Wedge ◽  
Emergency Hospital ◽  
Emergency Hospital Admissions ◽  
General Practices ◽  
Predictive Risk ◽  
Stepped Wedge Trial

AimWe evaluated the introduction of a predictive risk stratification model (PRISM) into primary care. Contemporaneously National Health Service (NHS) Wales introduced Quality and Outcomes Framework payments to general practices to focus care on those at highest risk of emergency admission to hospital. The aim of this study was to evaluate the costs and effects of introducing PRISM into primary care.MethodsRandomised stepped wedge trial with 32 general practices in one Welsh health board. The intervention comprised: PRISM software; practice-based training; clinical support through two ‘general practitioner (GP) champions’ and technical support. The primary outcome was emergency hospital admissions.ResultsAcross 230 099 participants, PRISM implementation increased use of health services: emergency hospital admission rates by 1 % when untransformed (while change in log-transformed rate ΔL=0.011, 95% CI 0.010 to 0.013); emergency department (ED) attendance rates by untransformed 3 % (while ΔL=0.030, 95% CI 0.028 to 0.032); outpatient visit rates by untransformed 5 % (while ΔL=0.055, 95% CI 0.051 to 0.058); the proportion of days with recorded GP activity by untransformed 1 % (while ΔL=0.011, 95% CI 0.007 to 0.014) and time in hospital by untransformed 3 % (while ΔL=0.029, 95% CI 0.026 to 0.031). Thus NHS costs per participant increased by £76 (95% CI £46 to £106).ConclusionsIntroduction of PRISM resulted in a statistically significant increase in emergency hospital admissions and use of other NHS services without evidence of benefits to patients or the NHS.

scholarly journals Kommunikasie as metode om verpleegsorg te verbeter

Curationis ◽  
1984 ◽  
Vol 7 (2) ◽  
Author(s):  
G. Postmus
Keyword(s):  
Patient Care ◽  
Nursing Care ◽  
Task Orientation ◽  
Academic Hospital ◽  
Oral Medications ◽  
Number Of Patients ◽  
Short Period ◽  
Hospital Wards ◽  
Quality Of Nursing

With the large number of patients in particularly academic hospital wards and the shortage of nursing staff total patient care is not possible. This is leading to increasing task-orientation and a widening of communication gaps which are affecting the quality of nursing care. One of the main problems is that it is impossible for nurses to remember all the details given during the regular reports off by heart. Neither does the nurse know which regular oral medications each patient is receiving. The nurse is thus unable to make the required observations while doing patient care and does not provide the necessary feedback. The author suggests a simple system, based mainly on the use of patient bed lists and a note book carried by each nurse to improve communication and achieve a higher standard of nursing care within a short period.

scholarly journals Understanding the implementation and medium-longer term sustainability of the primary care prescribing safety intervention, PINCER: preliminary results from a longitudinal process evaluation

2021 ◽  
Vol 29 (Supplement_1) ◽  
pp. i8-i9
Author(s):  
L Laing ◽  
N-E Salema ◽  
M Jeffries ◽  
A Shamsuddin ◽  
A Sheikh ◽  
...  
Keyword(s):  
Primary Care ◽  
Medication Errors ◽  
Evidence Synthesis ◽  
Controlled Trial ◽  
Cluster Randomised Controlled Trial ◽  
Health Science ◽  
Normalisation Process Theory ◽  
Routine Practice ◽  
Number Of Patients

Abstract Introduction Medication errors are an important cause of morbidity and mortality across primary care in England. In the National Health Service, approximately 71% of 237 million medication errors made annually are attributable to primary care(1). The complex pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) intervention has been shown to significantly reduce medication errors when tested in a cluster randomised controlled trial and when implemented on a larger scale across one geographical region of England. However, with a national rollout of PINCER now underway across England, there remains a limited understanding of whether and how wider implementation, impact and medium-longer term sustainability across diverse regions is achieved, and what factors may influence these processes. Aim This study aimed to explore the contextual factors that influenced the nature and extent of translation, implementation and sustained use of PINCER in diverse settings over time. Methods Intervention developers and personnel involved in the PINCER rollout and staff members from Academic Health Science Networks (AHSNs), Clinical Commissioning Groups (CCGs) and general practices from four regions of England, UK, were purposively recruited via research team connections and Clinical Research Networks. Interviews aimed to capture short-term (≤6 months), medium-term (6 – 18 months) and long-term (≥ 18 months) use of PINCER. Interview guides were informed by Normalisation Process Theory (NPT). Semi-structured, face-to-face or telephone interviews were conducted and digitally recorded. A preliminary thematic analysis was performed on the data collected. Results Forty-eight participants from 30 establishments, including two intervention developers, three involved in the PINCER rollout and five AHSN, seven CCG and thirty-one general practice employees were interviewed between June 2018 – June 2020. Their engagement with PINCER had either been in the medium (n=13) or long-term (n=17), (range 8 months - 5 years plus). Emerging themes identified in the preliminary analysis were: development and spread which incorporated intervention and training improvements as well as uptake, perceptions of PINCER which included awareness of PINCER as well as opinions on it and factors influencing the use of PINCER and sustainability which were mainly contextual but also related to PINCER functionalities. Within the development and spread theme, and relating to perceptions of PINCER theme, clear communication and ensuring there was an understanding of what PINCER entailed was considered important in initiating interest and uptake. Overall, PINCER was perceived positively. Key challenges to the implementation of PINCER identified were initial IT issues and workload. Policies advocating the use of PINCER, evidencing impact in reductions in the number of patients identified as being ‘at risk’ of hazardous prescribing and being able to benchmark results against other CCGs and practices helped facilitate the implementation and sustainability. Some changes made to prescribing and monitoring processes as a result of the implementation and use of PINCER, appeared to have become embedded into routine practice giving an indication of sustainable use. Conclusion Further interviews will establish if and how PINCER has been more widely adopted and normalised within primary care, in order to generate important learning to support its optimal and sustainable impact. References 1. Elliott R, Camacho E, Campbell F, Jankovic D, St James MM, Kaltenthaler E, et al. Prevalence and economic burden of medication errors in the NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. 2018.

Development and Performance Assessment of a Digital Serious Game to Assess Multi-Patient Care Skills in a Simulated Pediatric Emergency Department

2020 ◽  
Vol 51 (4) ◽  
pp. 550-570
Author(s):  
Cindy Luu ◽  
Thomas B. Talbot ◽  
Cha Chi Fung ◽  
Eyal Ben-Isaac ◽  
Juan Espinoza ◽  
...  
Keyword(s):  
Emergency Department ◽  
Diagnostic Accuracy ◽  
Patient Care ◽  
Skill Acquisition ◽  
Video Game ◽  
Rank Correlation ◽  
Fixed Time ◽  
Serious Game ◽  
Cross Sectional ◽  
Number Of Patients

Objective. Multi-patient care is important among medical trainees in an emergency department (ED). While resident efficiency is a typically measured metric, multi-patient care involves both efficiency and diagnostic / treatment accuracy. Multi-patient care ability is difficult to assess, though simulation is a potential alternative. Our objective was to generate validity evidence for a serious game in assessing multi-patient care skills among a variety of learners. Methods. This was a cross-sectional validation study using a digital serious game VitalSignsTM simulating multi-patient care within a pediatric ED. Subjects completed 5 virtual “shifts,” triaging, stabilizing, and discharging or admitting patients within a fixed time period; patients arrived at cascading intervals with pre-programmed deterioration if neglected. Predictor variables included generic multi-tasking ability, video game experience, medical knowledge, and clinical efficiency with real patients. Outcome metrics in 3 domains measured diagnostic accuracy (i.e. critical orders, diagnoses), efficiency (i.e. number of patients, time-to-order) and critical thinking (number of differential diagnoses); MANOVA determined differences between novice learners and expected expert physicians. Spearman Rank correlation determined associations between levels of expertise. Results. Ninety-five subjects’ gameplays were analyzed. Diagnostic accuracy and efficiency distinguished skill level between residency trained (residents, fellows and attendings) and pre-residency trained (medical students and undergraduate) subjects, particularly for critical orders, patients seen, and correct diagnoses (p < 0.003). There were moderate to strong correlations between the game’s diagnostic accuracy and efficiency metrics compared to level of training, including patients seen (rho = 0.47, p < 0.001); critical orders (rho = 0.80, p < 0.001); time-to-order (rho = −0.24, p = 0.025); and correct diagnoses (rho = 0.69, p < 0.001). Video game experience also correlated with patients seen (rho = 0.24, p = 0.003). Conclusion. A digital serious game depicting a busy virtual ED can distinguish between expected experts in multi-patient care at the pre- vs. post-residency level. Further study can focus on whether the game appropriately assesses skill acquisition during residency.

scholarly journals Heart Failure and Diabetes Mellitus: Biomarkers in Risk Stratification and Prognostication

2021 ◽  
Vol 11 (10) ◽  
pp. 4397
Author(s):  
Michael Lichtenauer ◽  
Peter Jirak ◽  
Vera Paar ◽  
Brigitte Sipos ◽  
Kristen Kopp ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Heart Failure ◽  
Ejection Fraction ◽  
Risk Stratification ◽  
Natriuretic Peptides ◽  
Predictive Ability ◽  
High Sensitivity ◽  
Routine Practice ◽  
Reduced Ejection Fraction ◽  
Novel Biomarkers

Heart failure (HF) and type 2 diabetes mellitus (T2DM) have a synergistic effect on cardiovascular (CV) morbidity and mortality in patients with established CV disease (CVD). The aim of this review is to summarize the knowledge regarding the discriminative abilities of conventional and novel biomarkers in T2DM patients with established HF or at higher risk of developing HF. While conventional biomarkers, such as natriuretic peptides and high-sensitivity troponins demonstrate high predictive ability in HF with reduced ejection fraction (HFrEF), this is not the case for HF with preserved ejection fraction (HFpEF). HFpEF is a heterogeneous disease with a high variability of CVD and conventional risk factors including T2DM, hypertension, renal disease, older age, and female sex; therefore, the extrapolation of predictive abilities of traditional biomarkers on this population is constrained. New biomarker-based approaches are disputed to be sufficient for improving risk stratification and the prediction of poor clinical outcomes in patients with HFpEF. Novel biomarkers of biomechanical stress, fibrosis, inflammation, oxidative stress, and collagen turn-over have shown potential benefits in determining prognosis in T2DM patients with HF regardless of natriuretic peptides, but their role in point-to-care and in routine practice requires elucidation in large clinical trials.

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