An Inpatient Rehabilitation Interprofessional Care Pathway for Traumatic Hip Fracture: A Pilot Quality Improvement Project

Background: Each year over 300,000 older adults are hospitalized for hip fracture. The impact of the cost of hip fracture on the US health care system is estimated to be as high as $9 billion, with the typical cost of a hip fracture episode around$30,000. Formalized pathways have been developed and successfully utilized for many patient presentations, including hip fracture, in the acute setting. Although this research is important to the comprehensive care of the elderly hip fracture patient, very little research exists that outlines evidence-based best-practice for patients in the post-acute recovery period. Purpose: The primary aim of this project was to develop an evidence-based, comprehensive, coordinated, and interprofessional care pathway for hip fracture patients in the acute rehabilitation setting to improve the percentage of patients discharging to community settings by 20% from current baseline by the end of the pilot period. Methods: The design of this project was an observational cohort study. Descriptive statistics will be used to compare intervention groups to controls, including frequencies and distributions. Results: The hip fracture tool itself had inconclusive results, the impacts of the effects on team work and enhanced coordination of the care team was realized through reducing institutionalized days for hip fracture patients in acute rehabilitation

Extending remote patient monitoring with mobile real time clinical decision support

Large scale implementation of telemedicine services such as telemonitoring and teletreatment will generate huge amounts of clinical data. Even small amounts of data from continuous patient monitoring cannot be scrutinised in real time and round the clock by health professionals. In future huge volumes of such data will have to be routinely screened by intelligent software systems. We investigate how to make m-health systems for ambulatory care more intelligent by applying a Decision Support approach in the analysis and interpretation of biosignal data and to support adherence to evidence-based best practice such as is expressed in treatment protocols and clinical practice guidelines. The resulting Clinical Decision Support Systems must be able to accept and interpret real time streaming biosignals and context data as well as the patient’s (relatively less dynamic) clinical and administrative data. In this position paper we describe the telemonitoring/teletreatment system developed at the University of Twente, based on Body Area Network (BAN) technology, and present our vision of how BAN-based telemedicine services can be enhanced by incorporating mobile real time Clinical Decision Support. We believe that the main innovative aspects of the vision relate to the implementation of decision support on a mobile platform; incorporation of real time input and analysis of streaming\ud biosignals into the inferencing process; implementation of decision support in a distributed system; and the consequent challenges such as maintenance of consistency of knowledge, state and beliefs across a distributed environment

Effect of guideline based computerised decision support on decision making of multidisciplinary teams: cluster randomised trial in cardiac rehabilitation

Objective To determine the extent to which computerised decision support can improve concordance of multidisciplinary teams with therapeutic decisions recommended by guidelines

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review.

Background: Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods: MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results: Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions: Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa

Translation of artemether–lumefantrine treatment policy into paediatric clinical practice: an early experience from Kenya

OBJECTIVE: To describe the quality of outpatient paediatric malaria case-management approximately 4-6 months after artemether-lumefantrine (AL) replaced sulfadoxine-pyrimethamine (SP) as the nationally recommended first-line therapy in Kenya. METHODS: Cross-sectional survey at all government facilities in four Kenyan districts. Main outcome measures were health facility and health worker readiness to implement AL policy; quality of antimalarial prescribing, counselling and drug dispensing in comparison with national guidelines; and factors influencing AL prescribing for treatment of uncomplicated malaria in under-fives. RESULTS: We evaluated 193 facilities, 227 health workers and 1533 sick-child consultations. Health facility and health worker readiness was variable: 89% of facilities stocked AL, 55% of health workers had access to guidelines, 46% received in-service training on AL and only 1% of facilities had AL wall charts. Of 940 children who needed AL treatment, AL was prescribed for 26%, amodiaquine for 39%, SP for 4%, various other antimalarials for 8% and 23% of children left the facility without any antimalarial prescribed. When AL was prescribed, 92% of children were prescribed correct weight-specific dose. AL dispensing and counselling tasks were variably performed. Higher health worker's cadre, in-service training including AL use, positive malaria test, main complaint of fever and high temperature were associated with better prescribing. CONCLUSIONS: Changes in clinical practices at the point of care might take longer than anticipated. Delivery of successful interventions and their scaling up to increase coverage are important during this process; however, this should be accompanied by rigorous research evaluations, corrective actions on existing interventions and testing cost-effectiveness of novel interventions capable of improving and maintaining health worker performance and health systems to deliver artemisinin-based combination therapy in Africa

ANESTHESIA PREOPERATIVE INCLUSION CRITERIA FOR TOTAL KNEE REPLACEMENT IN AMBULATORY SURGERY CENTERS: A CLINICAL PRACTICE GUIDELINE

Traditionally, total knee arthroplasty has been performed in the hospital setting. There has been a trend in healthcare that has moved this invasive procedure to the outpatient setting, in ambulatory surgery centers. In order for anesthesia providers to be prepared for the shift of this special population of patients, a clinical practice guideline was created to fulfill this scholarly project. It was expected that the application of this guideline would result in an increased use of the current evidence and the subsequent readiness of anesthesia providers to accept this patient population into surgery centers. It was also anticipated that the guideline would increase in safety for patients and demonstrate to surgeons and administration that it was appropriate to perform total knee replacement in ambulatory surgery centers. The scholarly project took place at South Ogden Specialty Surgery Center in Ogden, Utah, and included a thorough literature review, needs assessment, Delphi studies, and a proposed plan of implementation. It was hoped that the utilization of this guideline in the center would improve care and make a difference in the lives of patients

Increasing the intensity and comprehensiveness of aphasia services: identification of key factors influencing implementation across six countries

Background: Aphasia services are currently faced by increasing evidence for therapy of greater intensity and comprehensiveness. Intensive Comprehensive Aphasia Programs (ICAPs) combine these elements in an evidence-based, time-limited group program. The incorporation of new service delivery models in routine clinical practice is, however, likely to pose challenges for both the service provider and administering clinicians. This program of research aims to identify these challenges from the perspective of aphasia clinicians from six countries and will seek to trial potential solutions. Continual advancements in global communication technologies suggest that solutions will be easily shared and accessed across multiple countries. Aims: To identify the perceived and experienced barriers and facilitators to the implementation of 1) intensive aphasia services, 2) comprehensive aphasia services, and 3) ICAPs, from aphasia clinicians across six countries. Methods and procedures: A qualitative enquiry approach included data from six focus groups (n = 34 participants) in Australia, New Zealand, Canada, United States of America (USA), United Kingdom (UK), and Ireland. A thematic analysis of focus group data was informed by the Theoretical Domains Framework (TDF). Outcomes and results: Five prominent theoretical domains from the TDF influenced the implementation of all three aphasia service types across participating countries: environmental context and resources, beliefs about consequences, social/professional role and identity, skills, and knowledge. Four overarching themes assisted the identification and explanation of the key barriers and facilitators: 1. Collaboration, joint initiatives and partnerships, 2. Advocacy, the promotion of aphasia services and evidence-based practice, 3. Innovation, the ability to problem solve challenges, and 4. Culture, the influence of underlying values. Conclusions: The results of this study will inform the development of a theoretically informed intervention to improve health services’ adherence to aphasia best practice recommendations

Computerization of workflows, guidelines and care pathways: a review of implementation challenges for process-oriented health information systems

There is a need to integrate the various theoretical frameworks and formalisms for modeling clinical guidelines, workflows, and pathways, in order to move beyond providing support for individual clinical decisions and toward the provision of process-oriented, patient-centered, health information systems (HIS). In this review, we analyze the challenges in developing process-oriented HIS that formally model guidelines, workflows, and care pathways. A qualitative meta-synthesis was performed on studies published in English between 1995 and 2010 that addressed the modeling process and reported the exposition of a new methodology, model, system implementation, or system architecture. Thematic analysis, principal component analysis (PCA) and data visualisation techniques were used to identify and cluster the underlying implementation ‘challenge’ themes. One hundred and eight relevant studies were selected for review. Twenty-five underlying ‘challenge’ themes were identified. These were clustered into 10 distinct groups, from which a conceptual model of the implementation process was developed. We found that the development of systems supporting individual clinical decisions is evolving toward the implementation of adaptable care pathways on the semantic web, incorporating formal, clinical, and organizational ontologies, and the use of workflow management systems. These architectures now need to be implemented and evaluated on a wider scale within clinical settings

Use of Standardized Assessments and Online Resources in Stroke Rehabilitation

Background: The extent to which movement-related standardized assessments and online resources are used in stroke rehabilitation is unclear in the United States. Method: The researchers used a cross-sectional descriptive survey that examined (a) therapists use of movement-related standardized assessments, (b) factors influencing learning of new assessments, and (c) use of frequency of online resources by occupational therapists and physical therapists in the United States. Results: Of 151 respondents (46.4% occupational therapists, 53.6% physical therapists), the most frequently used movement-related assessments by occupational and physical therapists were the Berg and Fugl-Meyer Assessment, respectively. More physical therapists use motor-related standardized assessments regularly than occupational therapists, and physical therapists showed more consensus among standardized assessments. Both professions cited quality of patient care for motivating them to integrate outcome measures into practice. Most therapists in stroke rehabilitation used online resources to access movement-related standardized assessment content at least 25% of the time. The Rehabilitation Measures Database was the most frequently used website. Conclusion: Both occupational and physical therapists use online resources for movement-related standardized assessments on a regular basis. However, occupational therapists do not use standardized assessments as frequently as physical therapists. A systematic study of factors that impact the integration of standardized assessments is needed to further identify barriers and inform clinical practice change