Communication Whiteboards: Enhancing Patient, Family, and Care Team Communication

Abstract Replacement of non-template whiteboards strives to establish a standard of work around contents of bedside whiteboards across the Lehigh Valley Health Network. The overall goal of the boards is to improve communication, therefore increasing patient satisfaction and correspondence between caregivers. An initial prevalence audit was created and administered in 13 units and 4 Emergency Departments in July to gauge initial response to the new whiteboard system. HCAHPS scores were collected to establish a baseline measurement from fiscal year 2014 when non-template whiteboards were used. This data is to be compared with HCAHPS scores after standardized whiteboards are implemented, to evaluate change in communication between patients and caregivers. Introduction The use of communication whiteboards is common practice in many hospitals and health systems, but when boards are not standardized or blank, the information on them tends to be messy, difficult to understand, and generally makes communication experiences more confusing rather than improving clarity. Upon initial discussion of the whiteboard initiative, the team used literature to get a better idea of how other programs were using boards most effectively. According to a study by Dr. Niraj L. Sehgal (2010), “Most respondents also agreed that using template whiteboards (with predefined fields) to guide content would increase their use” (p. 236). The same study also suggested “patient whiteboards require defined goals, thoughtful planning, regular monitoring, and ongoing evaluation” (Sehgal 2010, p. 236). In relation to methods of use and measurement, Dr. Siddhartha Singh et al. (2011) strategized “patient satisfaction scores with communication were compared before and after placement of whiteboards” (p. 128), while Dr. Sehgal’s team recommended “one strategy to consider is having designated ‘auditors’ check whiteboards in each room, measuring weekly compliance and providing this feedback to nurse managers” (2010, p.238). Both teams’ reports advised that studies done in the future should focus on numerically confirming the effects of the newly implemented whiteboards using methods such as HCAHPS scores and Press Ganey responses. Methods A grand total of 1073 LVHN Communication Whiteboards will be implemented through this initiative. Multiple whiteboard templates were created to specifically address the needs of the unit in which they were being used. The project team consulted with administrators in each department to properly decide what was the most vital information to display on the whiteboards. The 12 templates created include Medical/Surgical, Critical Care, Transitional Skilled Unit, Pediatrics, Labor and Delivery, Labor and Delivery Triage, NICU, Emergency Department, ED-17th Street, ED-Children’s, Mom/Baby, and Perinatal. Another key component of the communication portion of the initiative was to ensure ease for patients and families more comfortable with other languages. The flipside of each English whiteboard is translated into Spanish. Another separate insert will be available in Arabic and Vietnamese, and can be switched into the mount when necessary. A license was also purchased to use the Wong Baker Faces Scale as a crucial pain-rating instrument. Once the whiteboard plans were created and finalized, a schedule of installation was created. As of this time, the majority of the boards have been installed into the units with the exception of a few which experiences some minor technical and delivery problems. A prevalence audit of 125 whiteboards was performed on July 1, 2014 in 13 units: 4T, 5CP, 5K, 6B, 6K, 6T, 7BP, 7C, 7T, ICU-M, RHC-M, TOHU, and TTU. An audit was performed on one board in PEDS but the data was eliminated because the entire unit had not had all the new boards installed at the time of the audit. The survey created for the audit included seven questions with three “If no,” or “describe”, sub-questions as follows Board had patient pain information completed (all 3 components). Patient confirmed that is the current pain goal. Today’s caregivers section is completed by every caregiver. If no, the caregivers that did complete today’s section are: Did non-nursing/provider (case management/therapy-PT-OT, etc.) complete their portion of the whiteboard when applicable? If no, list the discipline Auditor confirmed via assignment sheet that information is correct. Is the patient on any new medications? Please describe how often your nurse discussed you new medications and their side effect with you Please describe how satisfied you are with the explanation of your plan of care each shift. A separate audit of 33 boards was performed for ED-PEDS, ED-CC, ED-M, and ED-17. These audits applied the following questions: Board had patient score completed. Today’s caregivers section is completed by every caregiver. If no, the caregivers that did complete today’s caregiver section are: Auditor confirmed via assignment sheet that information is correct. “Awaiting” section has checkmarks. Auditor reviews status to see if board is up to date. Is there consistency between the “fall risk noted on board” and patient interventions (yellow socks and/or yellow wrist band)? Please describe how satisfied you are with the explanation of your plan of care. HCAHPS scores for fiscal year 2014 (prior to whiteboard installation) were collected and organized to create a baseline for comparison with scores after installation of the whiteboards. From the overall HCAHPS question, our baseline focused on the following categories: Communication with nurses Courtesy/Respect Listen carefully Explain well Communication with doctors Courtesy/Respect Listen carefully Explain well Pain Management Well controlled Medicine Explain meds Side effects Discharge Results A prevalence audit was done on July 1, 2014 in 13 units for a total of 125 completed surveys. Units are 4T, 5CP, 5K, 6B, 6K, 6T, 7BP, 7C, 7T, ICU-M, RHC-M, TOHU, TTU. There was some variation in the number of boards audited per unit, but all units ranged from 9-11 boards audited with the exception of ICU-M, which looked at 4 boards. A PEDS audit was done but has been removed due to lack of data and not all boards being placed at the date of audit. This audit is a preliminary look at response to the changing system, and it will be repeated regularly once all boards are in place and after to ensure consistent use. Auditor Confirmation Across the boards in all 13 units, the auditors confirmed via assignment sheet that the collected information was correct on 125/125. Pain – “Board had patient pain information completed (all 3 components)” 40/125 boards had all 3 components of patient pain information completed. TOHU had the best with 90% information completed, 5K and RHC-M had the worst outcome both reporting 0% information completed. 79/125 reported that the patient did confirm that their current pain goal was accurately recorded; TOHU had 100% correct pain goals recorded, 5K and 7BP had the worst outcomes with 18% correct pain goals recorded. Caregiver Section – “Todays caregivers section is completed by every caregiver” 73/125 reported all caregiver’s sections were completed. TTU and TC had the best outcome with 100% of caregiver section completed, while 7BP had the worst with 0% of the section completed. “If no, the caregivers that did complete today’s caregivers section are”: 2 boards were filled out doctor only, 44 nurses and tech only, and 6 tech only. Unit Doctor Only Nurses and Tech Tech only 4T 1 5CP 4 1 5K 6 1 6B 6 1 6K 1 6T 3 7BP 9 2 7C 7T 1 4 ICU-M 3 RHC-M 8 TOHU 1 TTU 74/125 non-nursing/providers completed their portion of the whiteboard when applicable. 5CP, 6K, and 7C had the best outcome with 100% completed; RHC-M had the worst outcome with 0% completed. New Medication – “Please describe how often your nurse has discussed your new medications and their side effects with you” 67/125 patients were on new medication when the audit was conducted. When asked “how often your nurse has discussed your new medications and their side effects with you” 11/67 answered always, 12/67 answered frequently, 24/67 answered occasionally, 20/67 answered never. Plan of Care – “Please describe how satisfied you are with the explanation of you plan of care each shift” 60/125 surveys reported patients feeling always informed about their plan of care; 7C had this highest reporting with 9/10 patients feeling always informed. 39/125 answered frequently informed, 18/125 answered occasionally informed, and 9/125 answered not informed. Emergency Departments ED-17, ED-CC, ED-M, and ED-PEDS were audited separately for a total of 33 boards. ED-PEDS had only 3 boards audited; the other 3 emergency departments had 10 boards each. Auditor confirmation The auditor confirmed via assignment sheet that 33/33 boards had the correct information, and the auditor confirmed 16/16 boards to be up-to-date. Pain 13/33 boards did had patient pain score completed Caregivers 23/33 boards had every caregiver section completed 7/11 caregiver sections were filled out by nurses only Awaiting Section 16/33 boards had an “Awaiting” section check-marked Fall Risk Consistency 9/33 surveys reported that there was consistency between “fall risk on board” and patient intervention. Plan of Care 20/33 patients felt always informed with their explanation of care Baseline HCAHPS HCAHPS scores for fiscal year 2014 (prior to whiteboard installation) were collected and organized to create a baseline for comparison with scores after installation of the whiteboards is completed. From the overall HCAHPS question, our baseline measurements focused on the following categories: Communication with nurses Courtesy/Respect Listen carefully Explain well Communication with doctors Courtesy/Respect Listen carefully Explain well Pain Management Well controlled Medicine Explain meds Side effects Discharge 4/10 of the section subcategories were above target for the YTD at Muhlenberg; Side effects were the lowest under target at 12.79 points under the Medicine category target for the year. 4/5 overall categories were above target for YTD; Communication with doctors came in 5.38 points under target for the year. 6/10 of the section subcategories were above target for the YTD at Cedar Crest; Side effects were the lowest under target at 13.49 points under the Medicine category target for the year. 4/5 overall categories were above target for YTD; Communication with doctors came in 1.58 points under target for the year. Discussion With the implementation of the communication whiteboards, the team expects to see improvements in the HCAHPS scores designated as relevant to whiteboard use. Along with HCAHPS scores, results of future prevalence audits should improve as staff gets more accustomed to using the board as a part of their regular routine. Based on the baseline HCAHPS report and the prevalence audit, the areas most necessary to improve are communication with doctors and discussion of new medications and side effects. The communication boards aim to aid in these areas by having information available for the patient to see at all times, and provide a visual reminder to the caregiver that these are topics that need to be attended to. Filling out the whiteboard will guide a two fold interaction for the patient/family and caregiver in which the information will be verbally conveyed, followed by visually displayed using images and categorized sections of information. Works Cited Singh, Siddhartha, Fletcher, Kathlyn E., Pandl, G. John, Shapira, Marilyn M., Nattinger, Ann B., Biblo, Lee A., et al. It\u27s the Writing on the Wall: Whiteboards Improve Inpatient Satisfaction With Provider Communication. American Journal of Medical Quality, 2011 26(2): 127-131. Retrieved June 10, 2014, from http://ajm.sagepub.com/content/26/2/127 Sehgal, Niraj L., Adrienne Green, Arpana R. Vidyarthi, Mary A. Blegen, and Robert M. Wachter. Patient Whiteboards as a Communication Tool in the Hospital: A Survey Of Practices And Recommendations. Journal of Hospital Medicine, April 2010 Vol 5, No 4: 234-239. Retrieved June 10, 2014, from Society of Hospital Medicine DOI 10.1002,jhm.63

Novel associations of bile acid diarrhoea with fatty liver disease and gallstones: a cohort retrospective analysis.

Background Bile acid diarrhoea (BAD) is a common cause of chronic diarrhoea with a population prevalence of primary BAD around 1%. Previous studies have identified associations with low levels of the ileal hormone fibroblast growth factor 19 (FGF19), obesity and hypertriglyceridaemia. The aim of this study was to identify further associations of BAD. Methods A cohort of patients with chronic diarrhoea who underwent 75selenohomocholic acid taurate (SeHCAT) testing for BAD was further analysed retrospectively. Additional clinical details available from the electronic patient record, including imaging, colonoscopy, chemistry and histopathology reports were used to calculate the prevalence of fatty liver disease, gallstones, colonic neoplasia and microscopic colitis, which was compared for BAD, the primary BAD subset and control patients with diarrhoea. Findings Of 578 patients, 303 (52%) had BAD, defined as a SeHCAT 7d retention value 31 ng/mL with imaging showing fatty liver (p40 IU/L. In 176 subjects with gallbladder imaging, 27% had gallstones, 7% had a prior cholecystectomy and 34% either of these. The median SeHCAT values were lower in those with gallstones (3.8%, p<0.0001), or gallstones/cholecystectomy (7.2%, p<0.001), compared with normal gallbladder imaging (14%). Overall, BAD had an OR of 2.0 for gallstones/cholecystectomy (p<0.05). BAD was not significantly associated with colonic adenoma/carcinoma or with microscopic colitis. Interpretation The diagnosis of BAD is associated with fatty liver disease and with gallstones. The reasons for these associations require further investigation into potential metabolic causes

Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus)

Researchers, practitioners, and policymakers develop interventions to change behavior based on their understanding of how behavior change techniques (BCTs) impact the determinants of behavior. A transparent, systematic, and accessible method of linking BCTs with the processes through which they change behavior (i.e., their mechanisms of action [MoAs]) would advance the understanding of intervention effects and improve theory and intervention development. The purpose of this study is to triangulate evidence for hypothesized BCT-MoA links obtained in two previous studies and present the results in an interactive, online tool. Two previous studies generated evidence on links between 56 BCTs and 26 MoAs based on their frequency in literature synthesis and on expert consensus. Concordance between the findings of the two studies was examined using multilevel modeling. Uncertainties and differences between the two studies were reconciled by 16 behavior change experts using consensus development methods. The resulting evidence was used to generate an online tool. The two studies showed concordance for 25 of the 26 MoAs and agreement for 37 links and for 460 "nonlinks." A further 55 links were resolved by consensus (total of 92 [37 + 55] hypothesized BCT-MoA links). Full data on 1,456 possible links was incorporated into the online interactive Theory and Technique Tool (https://theoryandtechniquetool.humanbehaviourchange.org/). This triangulation of two distinct sources of evidence provides guidance on how BCTs may affect the mechanisms that change behavior and is available as a resource for behavior change intervention designers, researchers and theorists, supporting intervention design, research synthesis, and collaborative research

Over-expression of c-Myc oncoprotein in oral squamous cell carcinoma in the South Indian population

Oral neoplasm constitutes a predominant class of cancer that is encountered in South India. This is in large part due to the elevated risk of oncogenesis as a result of the habit of chewing of quids containing betel leaves, areca nut and smokeless tobacco. An array of molecular events are induced during the transformation of the buccal epithelium, among them the over-expression of oncogene products plays a key role. The c-Myc protein, a regulator of a number of key cellular signalling pathways, plays a pivotal role in a number of malignancies. The present study was undertaken to evaluate expression of the c-Myc protein in tumours of the oral cavity from the South Indian population, predominantly oral squamous cell carcinoma (OSCC). The c-Myc protein was over-expressed in 80% of the cases studied. Taking into account the pivotal role demonstrated for c-Myc in tumourigenesis, our observations suggest a key role for Myc oncoprotein in the genesis of OSCC as well as its potential as a therapeutic target in this population

From Theory-Inspired to Theory-Based Interventions: A Protocol for Developing and Testing a Methodology for Linking Behaviour Change Techniques to Theoretical Mechanisms of Action

BACKGROUND: Understanding links between behaviour change techniques (BCTs) and mechanisms of action (the processes through which they affect behaviour) helps inform the systematic development of behaviour change interventions. PURPOSE: This research aims to develop and test a methodology for linking BCTs to their mechanisms of action. METHODS: Study 1 (published explicit links): Hypothesised links between 93 BCTs (from the 93-item BCT taxonomy, BCTTv1) and mechanisms of action will be identified from published interventions and their frequency, explicitness and precision documented. Study 2 (expert-agreed explicit links): Behaviour change experts will identify links between 61 BCTs and 26 mechanisms of action in a formal consensus study. Study 3 (integrated matrix of explicit links): Agreement between studies 1 and 2 will be evaluated and a new group of experts will discuss discrepancies. An integrated matrix of BCT-mechanism of action links, annotated to indicate strength of evidence, will be generated. Study 4 (published implicit links): To determine whether groups of co-occurring BCTs can be linked to theories, we will identify groups of BCTs that are used together from the study 1 literature. A consensus exercise will be used to rate strength of links between groups of BCT and theories. CONCLUSIONS: A formal methodology for linking BCTs to their hypothesised mechanisms of action can contribute to the development and evaluation of behaviour change interventions. This research is a step towards developing a behaviour change 'ontology', specifying relations between BCTs, mechanisms of action, modes of delivery, populations, settings and types of behaviour

Delivering Behaviour Change Interventions: Development of a Mode of Delivery Ontology [version 1; peer review: 1 approved, 1 approved with reservations]

Background: Investigating and improving the effects of behaviour change interventions requires detailed and consistent specification of all aspects of interventions. An important feature of interventions is the way in which these are delivered, i.e. their mode of delivery. This paper describes an ontology for specifying the mode of delivery of interventions, which forms part of the Behaviour Change Intervention Ontology, currently being developed in the Wellcome Trust funded Human Behaviour-Change Project. / Methods: The Mode of Delivery Ontology was developed in an iterative process of annotating behaviour change interventions evaluation reports, and consulting with expert stakeholders. It consisted of seven steps: 1) annotation of 110 intervention reports to develop a preliminary classification of modes of delivery; 2) open review from international experts (n=25); 3) second round of annotations with 55 reports to test inter-rater reliability and identify limitations; 4) second round of expert review feedback (n=16); 5) final round of testing of the refined ontology by two annotators familiar and two annotators unfamiliar with the ontology; 6) specification of ontological relationships between entities; and 7) transformation into a machine-readable format using the Web Ontology Language (OWL) language and publishing online. / Results: The resulting ontology is a four-level hierarchical structure comprising 65 unique modes of delivery, organised by 15 upper-level classes: Informational, Environmental change, Somatic, Somatic alteration, Individual-based/ Pair-based /Group-based, Uni-directional/Interactional, Synchronous/ Asynchronous, Push/ Pull, Gamification, Arts feature. Relationships between entities consist of is_a. Inter-rater reliability of the Mode of Delivery Ontology for annotating intervention evaluation reports was a=0.80 (very good) for those familiar with the ontology and a= 0.58 (acceptable) for those unfamiliar with it. / Conclusion: The ontology can be used for both annotating and writing behaviour change intervention evaluation reports in a consistent and coherent manner, thereby improving evidence comparison, synthesis, replication, and implementation of effective interventions

Delivering Behaviour Change Interventions: Development of a Mode of Delivery Ontology [version 2; peer review: 2 approved]

Background: Investigating and improving the effects of behaviour change interventions requires detailed and consistent specification of all aspects of interventions. An important feature of interventions is the way in which these are delivered, i.e. their mode of delivery. This paper describes an ontology for specifying the mode of delivery of interventions, which forms part of the Behaviour Change Intervention Ontology, currently being developed in the Wellcome Trust funded Human Behaviour-Change Project. Methods: The Mode of Delivery Ontology was developed in an iterative process of annotating behaviour change interventions evaluation reports, and consulting with expert stakeholders. It consisted of seven steps: 1) annotation of 110 intervention reports to develop a preliminary classification of modes of delivery; 2) open review from international experts (n=25); 3) second round of annotations with 55 reports to test inter-rater reliability and identify limitations; 4) second round of expert review feedback (n=16); 5) final round of testing of the refined ontology by two annotators familiar and two annotators unfamiliar with the ontology; 6) specification of ontological relationships between entities; and 7) transformation into a machine-readable format using the Web Ontology Language (OWL) and publishing online. Results: The resulting ontology is a four-level hierarchical structure comprising 65 unique modes of delivery, organised by 15 upper-level classes: Informational, Environmental change, Somatic, Somatic alteration, Individual-based/ Pair-based /Group-based, Uni-directional/Interactional, Synchronous/ Asynchronous, Push/ Pull, Gamification, Arts feature. Relationships between entities consist of is_a. Inter-rater reliability of the Mode of Delivery Ontology for annotating intervention evaluation reports was a=0.80 (very good) for those familiar with the ontology and a= 0.58 (acceptable) for those unfamiliar with it. Conclusion: The ontology can be used for both annotating and writing behaviour change intervention evaluation reports in a consistent and coherent manner, thereby improving evidence comparison, synthesis, replication, and implementation of effective interventions

Development of an Intervention Setting Ontology for behaviour change: Specifying where interventions take place

Background: Contextual factors such as an intervention's setting are key to understanding how interventions to change behaviour have their effects and patterns of generalisation across contexts. The intervention's setting is not consistently reported in published reports of evaluations. Using ontologies to specify and classify intervention setting characteristics enables clear and reproducible reporting, thus aiding replication, implementation and evidence synthesis. This paper reports the development of a Setting Ontology for behaviour change interventions as part of a Behaviour Change Intervention Ontology, currently being developed in the Wellcome Trust funded Human Behaviour-Change Project. Methods: The Intervention Setting Ontology was developed following methods for ontology development used in the Human Behaviour-Change Project: 1) Defining the ontology's scope, 2) Identifying key entities by reviewing existing classification systems (top-down) and 100 published behaviour change intervention reports (bottom-up), 3) Refining the preliminary ontology by literature annotation of 100 reports, 4) Stakeholder reviewing by 23 behavioural science and public health experts to refine the ontology, 5) Assessing inter-rater reliability of using the ontology by two annotators familiar with the ontology and two annotators unfamiliar with it, 6) Specifying ontological relationships between setting entities and 7) Making the Intervention Setting Ontology machine-readable using Web Ontology Language (OWL) and publishing online. Results: The Intervention Setting Ontology consists of 72 entities structured hierarchically with two upper-level classes: Physical setting including Geographic location, Attribute of location (including Area social and economic condition, Population and resource density sub-levels) and Intervention site (including Facility, Transportation and Outdoor environment sub-levels), as well as Social setting. Inter-rater reliability was found to be 0.73 (good) for those familiar with the ontology and 0.61 (acceptable) for those unfamiliar with it. Conclusion: The Intervention Setting Ontology can be used to code information from diverse sources, annotate the setting characteristics of existing intervention evaluation reports and guide future reporting

Dynamically Triangulating Lorentzian Quantum Gravity

Fruitful ideas on how to quantize gravity are few and far between. In this paper, we give a complete description of a recently introduced non-perturbative gravitational path integral whose continuum limit has already been investigated extensively in d less than 4, with promising results. It is based on a simplicial regularization of Lorentzian space-times and, most importantly, possesses a well-defined, non-perturbative Wick rotation. We present a detailed analysis of the geometric and mathematical properties of the discretized model in d=3,4. This includes a derivation of Lorentzian simplicial manifold constraints, the gravitational actions and their Wick rotation. We define a transfer matrix for the system and show that it leads to a well-defined self-adjoint Hamiltonian. In view of numerical simulations, we also suggest sets of Lorentzian Monte Carlo moves. We demonstrate that certain pathological phases found previously in Euclidean models of dynamical triangulations cannot be realized in the Lorentzian case.Comment: 41 pages, 14 figure

Atrial and placental melanoma metastasis: a case report and literature review

Malignant melanoma can metastasize to virtually any organ of the body. The aggressiveness is determined by the primary site, depth of dermal invasion, presence or absence of ulceration, lymphovascular infiltration and regional lymph node involvement. We report a case of a pregnant woman with a previous history of stage 3 melanoma who presented with cardiac metastasis and placental melanoma infiltration. A review of literature on cardiac and placental involvement of melanoma is also provided