Technology-Based Advance Care Planning Education for Primary Care Patients

Background: Advance Care Planning (ACP) encompasses a multidisciplinary, collaborative process that allows patients to understand their health and make informed decisions in their treatment plans. Considering the COVID-19 pandemic and recent research, ACP is considered imperative for all patients. Evidence-based approaches include supplemental group sessions, case manager interventions, and provision of at-home resources. Within the pandemic, there has also been a rapid shift to telemedicine, restricting most ACP efforts. Therefore, the utilization of technology-based ACP resources and telemedicine is highly supported. Purpose: This DNP project serves to assist an internal medicine practice located in Hawaii’s metropolitan area. Although the hospital system has previously made significant headway in ACP promotion, the COVID-19 pandemic has made primary providers even more aware of its significance. New workflows are needed to accommodate time restrictions, telehealth restrictions, and ACP reimbursement requirements. Methods: The medical assistant (MA) provided patients a pre-visit survey during their appointment reminder. The survey included two video decision aids on ACP. During the appointment, the provider discussed the pre-visit survey and videos. After the visit, patients were given a survey to gauge changes in their ACP process and provide appropriate resources based on learning style and ACP needs. ACP discussion was documented and billed according to Centers for Medicare Service guidelines (CMS, 2020). Results: 15 patients were enrolled in the study and completed the pre-visit survey. ACP engagement survey scores ranged from 3.9 to 4.5, indicating readiness for change. 1 patient completed the post-visit survey but showed no change in score. Annual ACP goal was met in 8 of 15 patients. 7 patients had a completed an AD, 2 of which during the project. Staff sited increased ACP awareness, increased time efficiency during visits, and overall satisfaction with project outcomes. Conclusion: Advanced Care Planning is a relevant quality care measure that is essential to primary care regardless of patient health status. ACP can be promoted without introducing extraneous personnel or drastically altering MA and provider workflows. Patients and staff voice positive feedback to video decision aids and screening tools. However, opposition to technology is prominent in the elder patient population. In this, adequate planning, introduction, and implementation time is required to accommodate barriers to participation. Lastly, culturally sensitive and community-based resources are accessible and complementary to evidence-based methods

Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial

Background: Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome. Methods: In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134. Findings: Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88–1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90–1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41–0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22–3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31–0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64–0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37–3·91], p=0·771) was similar. Interpretation: In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status

A Patient-Facing Dashboard to Promote Shingrix™ Vaccination in a Continuing Care Retirement Community: A Quality Improvement Project

BACKGROUND: Shingles is considered one of the most significant vaccine-preventable diseases of older adults based on its morbidity and public health burden, which increase drastically with age. Adult vaccine awareness and promotion programs are undervalued in the U.S.; in particular, educational programs targeting older adults are needed. Older adults have increasing rates of adoption of health information technology (HIT) to seek guidance and support for their medical needs. Leveraging HIT in the form of clinical dashboards is an option for providing reliable, safe and cost-effective vaccine education to older adults at high risk of vaccine-preventable disease. METHODS: The specific aims of this quality improvement project were to increase knowledge and uptake of recombinant zoster vaccine (Shingrix™) in older adults of a continuing retirement community (CCRC) through creation of a patient-facing clinical dashboard. The Four Pillars™ practice transformation program was used to guide implementation of the project including utilization of self-report surveys to determine baseline vaccination rates, perceptions of the dashboard and behavioral intention to receive future vaccination. The Patient Portal Acceptance Model (PPAM) was used as a theoretical framework to evaluate respondents’ perceptions of the dashboard across four domains: ease of use, usefulness, self-efficacy, and privacy/security. RESULTS: Respondents reported high levels of education and computer literacy. The majority reported using the internet for over 20 years and over 10 hours per week and 77.8% had used the internet to search for healthcare information within the past year. Baseline Shingrix™ vaccination levels in the CCRC were higher than national average but not at goal rates, and the majority of respondents eligible for vaccination did not plan to receive it. Respondents rated the dashboard moderately high on perceived ease of use, low on concerns about privacy/security, high on ability to use independently (self-efficacy), and low on perceived usefulness. DISCUSSION: The information provided by CCRC residents during development of this dashboard was valuable for elucidating motivators and barriers to HIT use in older adults, who largely view HIT as an adjunct to in-person interaction with a trusted provider. Improving older adults’ perceptions of HIT will be critical in the era of Covid-19, when many high-risk older adults are seeking alternatives to traditional provider visits. Respondents were willing and able to access and navigate the dashboard; however, shingles knowledge did not improve in this small sample. Improvements in the presentation of the material on the dashboard may improve perceptions of usefulness and comprehension of specialized clinical information. CONCLUSION: CCRC residents were receptive to receiving vaccine information via electronic dashboard and expressed interest in using this format as a source of other healthcare information. There is ample opportunity to expand patient-facing dashboards in the CCRC setting to provide a wide array of healthcare education for this population

State Primary Stroke Center Policies in the US: Rural Health Issues.

Objective: To explore the relationship between state primary stroke center (PSC) designation policy implementation and access to optimal stroke care for residents of rural areas. Materials and Methods: Primary data were collected during the period September 2008–August 2009. Following content analysis of state PSC policies, four case study states were selected for fieldwork, in part for state rural healthcare access challenges. Variables included the barriers and facilitators to PSC designation policy implementation. More than 100 semistructured stakeholder interviews were conducted by teams of researchers. Large-group meetings were also observed. Interview summaries were reviewed by stakeholders for accuracy and completeness. Results: The consistent finding in all study states was that PSC designation and state policy implementation in rural areas are unlikely for a variety of reasons, including lack of financial resources for telemedicine, difficulty maintaining neurology coverage, and emergency departments unable to administer thrombolytics. Findings indicate recognition by states about the need for stroke-care public policy specific to telemedicine in rural areas. Conclusions: Although state PSC designation policies raise awareness of rural issues, designation policy alone cannot overcome the obstacle of rural access to optimal stroke care. States must be technology-ready, and providers need to embrace e-health and telemedicine to ensure coordination of care for stroke victims in rural areas. More important is that state policy makers should provide rules and regulations to encourage PSC hospitals to use telemedicine and “proxy credentialing” to support their affiliated rural facilitie

Implementation of Advance Directive Screening Education in the Hospital Setting

The Patient Self Determination Act of 1991 mandates that Registered Nurses (RNs) must screen patients for advance directives (ADs) during hospital admissions. When ADs are not completed, there is a possibility that unwarranted and costly treatment options will be offered. Unjustified actions create an environment of financial and emotional load for families and our national healthcare system. Over 39 million Americans are hospitalized each year (65 and older years of age). This will exceed 71.2 million by 2030 (182% increase); nationwide, only 33% of U.S. adults have an AD. To increase AD education among Medicine Intensive Care Unit (MICU) RNs at a large, urban hospital located in southeastern United States, a quality improvement (QI) study was conducted. Prior to the initiation of the Doctor of Nursing Practice (DNP) QI initiative, it was identified that a large percentage of patients admitted to the MICU were not being screened, demonstrated by AD screening completion of 57.21%. Institutional policy required 90%. Interventions were intended to address barriers to completion that were identified in a pre-implementation screening survey. The project was designed and introduced to the MICU participants. Various interventions were created and implemented throughout four PDSA cycles over four months. Fifty chart audits were completed each month from April through November, including pre-implementation and post-implementation data. With the implementation of numerous interventions as well as an institutional system change specific to EHR audit requirements, compliance of 90% was achieved. The DNP project site is now equipped to maintain sustainability.D.N.P

‘The Going Digital Study’ – The implementation of electronic patient records in a paediatric tertiary hospital: Understanding the benefits and challenges for patients, parents and staff and the practical, ethical and legal implications

BACKGROUND: The Going Digital Study uniquely captured the experiences of all user groups before and after digital transformation of Great Ormond Street Hospital for Children (GOSH) whilst implementing an electronic patient record (EPR) system with a tethered patient portal in April 2019. This was critical and core to GOSH becoming a digital hospital, with benefits anticipated, yet challenges for all. AIM: To investigate the practical, ethical and legal considerations of implementing an EPR in a children’s tertiary hospital involving three stakeholder groups: children and young people (CYP), parents and staff. METHODS: A three phase, concurrent mixed methods, pre/post study design was utilised including both quantitative (survey) and qualitative (World Café workshops/interviews/focus group) data collection, analysis and synthesis. A systematic review of the literature was also conducted and was key to informing the examination of the experiences of users of an electronic patient record system in a children’s hospital setting and interpretation of the findings. RESULTS: Despite the challenges experienced by all stakeholders, including ethical and legal issues associated with CYP and parents accessing health data for the first time through the patient portal, meaningful portal access can be achieved from the age of 12 years of age. Families need support accessing health information via the portal. Clinicians need to have early conversations with parents about truth-telling and sharing diagnoses and/or prognoses, supporting families through the process of disclosure. Staff need prolonged support to balance clinical demands during implementation of and adjustment to the new clinical system, whilst continuing care provision and managing families’ expectations. CONCLUSION: Implementation and transition to an EPR system with a tethered patient portal is complex and takes time to embed. Setting realistic expectations and involving all stakeholders at all stages is paramount if benefits for all are to be fully realised. Managing this change process well, with prolonged engagement over time with all stakeholders, is essential if future utility is to be achieved. This requires an inclusive culture, in which the voice of all children and young people and parents is valued, and enabled through investment of appropriate resources, with equity of access a key priority

Improving efficiency in stroke trials: an exploration of methods to improve the use of the modified Rankin Scale in acute stroke trials

The modified Rankin Scale (mRS) is the preferred outcome measure in stroke trials. Typically, mRS assessment is based on a clinician’s rating of a patient interview and interobserver variability is common. Meta-analysis suggests an overall reliability of k=0.46 but this may be less (k=0.25) in multi-centre studies. Mandatory training in mRS assessment is employed in most trials to mitigate this but the problem persists. Variability in assigning outcomes may lead to endpoint misclassification increasing the challenge of accurately demonstrating a treatment effect. We aimed to assess the impact of endpoint misclassification on trial power and explore methods to improve the use of the mRS in acute stroke trials. First we used the mRS outcome distributions of previous phase III randomised controlled trials (RCT) in stroke (NXY059 study and tPA NINDS study) to perform statistical simulations. We generated power estimates and sample sizes from simulated mRS studies under various combinations of sample size, mRS reliability and adjudication panel size. Simulations suggest that the potential benefit of improving mRS reliability from k 0.25 to k 0.5, k 0.7 or k 0.9 may allow a reduction in sample size of n= 386, n= 490 or n= 488 in a typical n=2000 RCT. We then developed a method for providing group adjudication of mRS endpoints and examined the feasibility, reliability and validity of its use in a multicentre clinical trial. We conducted a “virtual” acute stroke trial across 14 UK sites. Local mRS interviews were scored as normal but also recorded to digital video camera. Video clips were uploaded via secure web portal for scoring by adjudication committee reviewers. We demonstrated excellent technical success rates with acceptability to both participants and investigators. 370 participants were included in our “virtual” acute stroke trial and 563 mRS video assessments were uploaded for central review. 96% (538/563) of study visits resulted in an adjudicated mRS score. At 30 and 90 days respectively, 57.5% (161/280) and 50.8% (131/258) of clips were misclassified. Agreement was measured using kappa statistics (k/kw) and intraclass correlation coefficient. Agreement between the adjudication committee was very good (30 days kw 0.85 [95%CI 0.81-0.86], 90 days kw 0.86 [95% CI 0.82-0.88]) with no significant or systematic bias in mRS scoring in comparison to the local mRS. We demonstrated criterion and construct validity of centrally adjudicated mRS scores through comparison with the locally assigned mRS score and other measures known to affect stroke outcome including baseline NIHSS (bNIHSS), Systolic Blood Pressure (SBP), blood glucose and home time. We studied our cohort of mRS video clips to identify any features predictive of variability in mRS scoring. Patient specific variables included participant age, pre stroke mRS, baseline stroke severity as graded by baseline NIHSS (bNIHSS) and presence of language disorder. Interview specific variables included length of interview, poor sound quality, location of the interview, use of a proxy or discussion of prior disability. At both 30 and 90 days only “interview length” was a significant predictor of agreement in mRS scoring. Using a sample of mRS video clips in English and Mandarin, we conducted a pilot study to assess the effect of translation of mRS interviews on interobserver reliability. The interobserver reliability of the translated mRS assessments was similar to native language clips (Native (n=69) kw 0.91 [95%CI 0.86-0.99], Translated (n=89) kw 0.90 [95% CI 0.83-0.96]). We then incorporated a translation step into the central adjudication model using our existing web portal. Inter observer reliability seen in the modified clips (kw 0.85 [95% CI 0.74-0.95]) was similar to that seen in the original video files (kw 0.88 [95% CI 0.78-0.99]). Finally we aimed to investigate the ability of raters to detect more subtle degrees of disability within mRS ranks through blinded assessment of pairs of clips with matching mRS grades. These pairs contained either two clips with full agreement in mRS grade at initial group review or one clip with full agreement and one clip where scores were skewed in the direction of “more” or “less” disability. Pairs were randomly assigned to multiple raters. We could not identify any reliable pattern in identification of the “less disabled” mRS clip. More sensitive grading of the mRS with “good” or “bad” forms of each grade is not reliable on the basis of this exploratory study. Perhaps alternative methods of converting the ordinal ranks of the mRS scale into a more continuous distribution should be investigated; such as the use of a mean mRS score following multiple mRS ratings. Prior estimates of mRS reliability in multicentre studies are poor [k=0.25]. The risks of endpoint misclassification affecting trial power are substantial. Simulations suggest that the effect of improving interobserver reliability and multiple mRS assessments may reduce study sample size by 25%, resulting in substantial ethical and financial benefits. Agreement between our adjudication committee was good [k=0.59(95% CI:0.53-0.63), kw=0.86(95% CI:0.82-0.88)]. Central review may bring many additional potential benefits: “expert” review, quality control and improved blinding in complex trial design. Central adjudication of mRS assessments is feasible, reliable and valid, including the use of translated mRS assessments. This model of outcome assessment has been incorporated into four ongoing large clinical trials: CLEAR-3, MISTIE-3, EUROHYP-1 and SITS-OPEN