Improving the Coordination of Care for Periprocedural Antithrombotic Medication Management in Patients Undergoing Elective Surgery

Background: Arranging periprocedural antithrombotic medication (ATM) management is a frequently encountered complex clinical challenge. Often, there is limited time between the pre-admission clinic visit and the surgical date to coordinate ATM management and communicate the plan to the patient. This increases the risk of perioperative adverse events, case delays and cancellations, and is a patient safety concern. A quality improvement project was undertaken to address improving ATM periprocedural care coordination for patients taking ATM undergoing elective surgery. A review of the literature found clinical decision support system (CDSS) alerts to be an effective strategy. The aim of the project was to improve the quality and safety of ATM by optimizing the care coordination pathway for periprocedural ATM management. Methods: A multidisciplinary team was formed to collaborate on the project aims,intervention, and implementation plan. The intervention was a computer application for auto-identification and flagging of ATM to deploy a CDSS alert for referral to an online workflow organization tool (list manager) to coordinate ATM periprocedural management. Current state analysis was conducted. Results. Qualitative and quantitative evidence demonstrated variation across surgical services in coordinating periprocedural ATM management. This data supported project approval by senior leadership. Request for programming was submitted. Planning for piloting the intervention in two clinical areas where bleeding is of critical concern continues. Conclusion. The project was complex in both scope and design, affecting multiple stakeholders with competing concerns. In the first iteration, the request for programming the CDSS alert was denied. This required the project team to pivot to an alternative solution, an online workflow organization tool (list manager) and extended the project timeline. Recommendations: This quality improvement project demonstrates the need for further quality improvement initiatives and research on improving the coordination of periprocedural ATM management. It highlights the complexity of this care coordination process

Development and preliminary results of an Electronic Medical Record (EMR)-integrated smartphone telemedicine program to deliver asthma care remotely

Background: Technology-based interventions that can function within real-world practice and improve outcomes without increasing provider burden are needed, yet few successfully cross the research-to-practice divide. This paper describes the process of developing a clinically-integrated smartphone-telemedicine program for adults with asthma and results from proof-of-concept testing. Methods: To ensure integration with practice, we used a contextually-grounded intervention development approach and May\u27s implementation theory to design the intervention, with emphasis on systems capabilities and stakeholder needs. The intervention incorporated symptom monitoring by smart phone, smartphone telemedicine visits and self-management training with a nurse, and clinical decision support software, which provided automated calculations of asthma severity, control, and step-wise therapy. Seven adults (aged 18-40) engaged in a 3-month beta-test. Asthma outcomes (control, quality of life, FEV1) and healthcare utilization patterns were measured at baseline and end-of-study. Results: Each participant received an average of 4 telemedicine visits with 94% patient satisfaction. All participants had uncontrolled asthma at baseline; by end-of-study 5/7 classified as well controlled. Mean asthma control improved 1.55 points (CI=0.59-2.51); quality of life improved 1.91 points CI=0.50-3.31), and FEV1 percent predicted increased 14.86% (CI=-3.09-32.80) with effect sizes of d=1.16, 1.09, and 0.96, respectively. Preventive healthcare utilization increased significantly (1.86 visits/year vs. 0.28/year prior, CI 0.67-2.47) as did prescriptions for controller medications (9.29 refills/year vs. 1.57 refills/year, CI 4.85-10.58) Conclusion: Smartphone telemedicine may be an effective means to improve outcomes and deliver asthma care remotely. However, careful attention to systems capabilities and stakeholder acceptability is needed to ensure successful integration with practice

The Value of Information Technology-Enabled Diabetes Management

Reviews different technologies used in diabetes disease management, as well as the costs, benefits, and quality implications of technology-enabled diabetes management programs in the United States

Mind the gap! Guideline implementation for peripheral venous catheters in paediatric care : documetation, complications, adherence and context

Introduction: There is a knowledge translation gap between evidence, based on research findings and clinical practice. Clinical practice guidelines (CPGs) have been proposed as a strategy to condense and disseminate research findings. However their existence alone does not minimise the gap, they have to be implemented in everyday practice. Registered nurses’ (RNs) work context influences their research use, but little is known on what contextual factors that influence RNs’ adherence to CPGs. Computer reminders have shown potential to minimise the knowledge translation gap, but insights into their effect on patients’ outcomes, RNs’ adherence and in what context they are most effective is still understudied. Aim: to evaluate the effects of implementing recommendations from a CPG for peripheral venous catheters (PVCs) as reminders in electronic patient records (EPR) and to describe factors of importance for the implementation process and outcomes. Methods: the setting for all four papers was a large paediatric university hospital in Sweden. Data for paper I was collected from 14 inpatient units through observations of patients and PVCs, and audit of EPRs. This was carried out at baseline and than two times after implementing a documentation template for PVCs. Data on PVCs and patients for paper II were retrieved from the EPR at 12 inpatient units, divided into neonatal and paediatric units. Paper III was a cross-sectional survey, including 23 in- and outpatient units. Data was collected through a questionnaire concerning RNs’ adherence to CPG recommendations and their work context, measured by the Alberta Context Tool (ACT). Paper IV was a cluster randomised study, at 12 inpatient units, with computer reminders based on the CPG. A stratified randomisation of units, based on occurrence of PVCs, was performed. The primary outcome was documented signs and symptoms of PVC-related complications at removal and secondary outcome was RNs’ adherence to the CPG, and their work context measured by the ACT. Results: A statistical, not clinical, significant increase of PVCs with complete documentation was the result of the PVC template. One of the 22 complications observed at baseline was documented and none of the complications (n=17 and n=9) post-intervention (paper I). Just over one-third (35.4%) of the patients were affected by a PVC-related complication, with infiltration and occlusion occurring most frequently. Complications were more common in younger age patients (paper II). Work context, in the form of structural and electronic resources, information sharing activities, and evaluation, was in different ways associated with RNs’ adherence to the CPG recommendations (paper III). Ninetyone percent of the RNs adhered to the CPG recommendation of disinfection of hands, 64% to usage of disposable gloves and 54% to daily inspection PVC insertion site (paper III). There was no significant effect of the computer reminders, neither on PVC-related complications nor on RNs’ adherence to the guideline recommendations (paper IV). RNs score of their context in both groups (intervention and control) varied from moderately low to moderately high. Conclusion: The EPR did not provide accurate data on PVCs either before or after the implementation of a PVC template. PVC-related complications, specifically infiltration and occlusion, were common, particularly among younger aged patients. RNs adhered to the recommendation on disinfection of hands, while the use of disposable gloves and daily inspection of PVC insertion site showed greater improvement potential. Diverse contextual factors were in different ways associated with RNs’ adherence to the CPG recommendations. The computer reminders did not have any significant effect on PVC-related complications, or on RNs adherence to the CPG recommendation

A Multi-Method Evaluation Of A Guideline Based Clinical Decision Support Intervention On Provider Ordering Behavior, System Acceptance And Inter-Professional Communication

Background and aims: Unnecessary variation in the delivery of patient care is well documented in the medical literature; evidence-based clinical practice is critical for improving the quality of care. Clinical decision support systems (CDSS) are promising tools for improving the systematic integration of evidence into clinical practice. This study evaluated a CDSS in a domain of care that had not yet been explored—namely, decision support for venous catheter selection. This dissertation study aimed to (1) evaluate the effect of this CDSS on provider ordering behavior before and after implementation and explore the differential impact of this tool by provider type and service and (2) identify organizational, individual, usability, and workflow factors that impact CDSS acceptance by physicians and advanced practice nurses and to elicit information about the impact of this system on communication between providers and the nurse-led vascular access team. Methods: This was a multi-method study. Aim one was single group pre-post analysis of longitudinal data. Variables included those related to patient and provider level factors. The main analysis was conducted with linear regression models with random effects to account for clustering of data. We conducted semi-structured interviews for aim two and use conventional qualitative content analysis to identify themes. Results: We found mixed results in the impact of the CDSS on provider ordering behavior. While the CDSS did not have an impact on the number of venous catheters ordered, we saw a statistically and clinically significant decrease in the proportion of double lumen catheters ordered. Findings for the qualitative aim showed that the CDSS improved process efficiency and inter-professional communication. We found that it also facilitated education for evidence based practice for novice providers. Discussion: This dissertation study showed a clear impact of the CDSS on double lumen catheter ordering, which has implications for patient outcomes. Furthermore, we found impacts by provider type. Additional work is needed to evaluate this CDSS in other settings and to further assess differential impacts by provider type

An Examination of Factors Affecting Hemoglobin A1c Levels and Self-Care Behaviors among Type 2 Diabetic Patients in the Primary Care Setting

Despite all of the research that has demonstrated the importance of optimal control of diabetes, there are still many people who do not receive adequate care, education, and support in managing their diabetes (Barnard, Peyrot, & Holt, 2012; Rossi et al., 2015). This cross-sectional, descriptive, study examined the effects of the components of the Chronic Care Model on the outcomes of self-care behaviors and HbA1c levels for Type 2 diabetes patients cared for by nurse practitioners and physicians in the primary care setting. Specifically, this study examined the effects of self-management support, conceptualized as patient perceptions of patient activation, participation in decision-making, and practitioner facilitation of patient involvement in care. This study also examined the elements of the model together (community resources, self-management support, decision support, clinical information systems and delivery system design) for their combined and individual effect on patient self-care behaviors and HbA1c levels. Participants of this study were diagnosed with type 2 diabetes, 18 years of age or older, and currently seeing a physician or nurse practitioner within a primary care setting for the care and management of their type 2 diabetes. Participants (N=82) completed a total of 6 questionnaires which included a demographics form, the Patient Activation Measure (PAM), the Facilitation of Patient Involvement Scale (FPI), the Perceived Involvement in Care Scale (PICS), and Patient Assessment of Care for Chronic Conditions (PACIC), and the Summary of Diabetes Self-Care Activities (SDSCA). The PACIC was found to have significant associations with General Diet Score (p=.020), Specific Diet Score (p=.027), exercise (p=.032), and blood glucose testing (p=.046). The PAM was found to have significant associations with General Diet Score (p=.023) and foot care (p=.006). The FPI was found to have a significant association with blood glucose testing (p=.030). The PICS was found to have a significant association with blood glucose testing (p=.046). The results were helpful to address some of the questions related to HbA1c and self-care behavior practices. Of notable importance, having no statistical significance in the results when comparing nurse practitioner patients and physician patients demonstrates that, in this particular study, there was no difference in the standards and variables that were measured comparing nurse practitioners and physicians. The patients who were cared for by both types of providers experienced similar outcomes with regard to self-care behaviors, HbA1c, levels of patient activation, participation in decision-making, and facilitation of patient involvement in care. Therefore, this is an important finding supporting the notion that care received by nurse practitioner patients and physician patients is not different

Improving Foot Care and Kidney Disease Screening Through Implementation of American Diabetes Association Standards–2016 in The Primary Care Setting

The purpose of this quality improvement project was to increase adherence to the American Diabetes Association Standards of Medical Care in Diabetes—2016 recommendations for foot care and kidney disease screening for patients with diabetes mellitus type II in a primary care setting. Diabetes mellitus type II affects approximately 18.9-19.9 million, or 90-95%, of all diagnosed cases in the United States. Early detection and management decrease the risk of developing microvascular complications that may lead to neuropathy and nephropathy. Adults with diabetes mellitus type II, 20 years of age and older, accounted for approximately 73,000 non-traumatic lower-extremity amputations in 2011. Diabetes is the leading cause of kidney failure representing 44% of all new cases of renal failure. This quality improvement project was implemented by providing education for medical assistants and the provider. A pre-intervention audit of 50 charts revealed 10% documentation of foot care performed, 6% screening of kidney disease via microalbumin/creatinine testing, and 0% documented provision of educational handouts in patients with diabetes mellitus type II. For the quality improvement project the clinic began to perform and document foot care and order urine microalbumin/creatinine test more consistently with these recommendations. A post-intervention audit of 50 charts showed 50%, achievement in foot care performed and documented, 26 % achievement in microalbumin/creatinine testing, and 0% documentation of educational material. This project led by a Doctor of Nursing Practice student encompasses a higher level of clinical evaluation, organizational leadership and responsibility in providing evidence-based care

Implementation of an Electronic Alert for Improving Adherence to Diabetic Foot Exam Screenings in Type 2 Diabetic Patients in Primary Care Clinics

Practice Problem: Patients with type 2 diabetes mellitus (T2DM) are at an increased risk of complications including foot ulcerations (Harris-Hayes et al., 2020). Preventive care is essential for the early detection of foot ulcers but despite the advantages of preventive screening, a limited number of primary care providers perform annual foot exams (Williams et al., 2018). PICOT: The clinical question that guided this project was, “In adult patients with T2DM receiving care in a primary care setting, will the implementation of an electronic clinical reminder alert (ECR) increase provider adherence to performing an annual diabetic foot exam and risk assessment, compared to adherence rate pre alert implementation, in 30 days?” Evidence: Evidence indicates that ECR alerts to remind providers to perform foot exams improve provider adherence to perform annual foot exams. Intervention: An ECR alert was implemented to remind providers to perform an annual diabetic foot exam to increase provide adherence. Outcome: Twenty-three patients had a completion rate of 46% for their annual diabetic foot exam pre intervention implementation and 45 patients had a completion rate of 56.25% post intervention implementation. There was no statistical significance noted but an increase in provider adherence in performing foot exams, which suggests clinically significant outcomes. Conclusion: Annual foot exams and an ECR alert to remind providers to perform foot exams on people with diabetes can help improve health outcomes in diabetic patients