Improving older people's care in one acute hospital setting: a realist evaluation of a KT intervention

Background: Older people make up an increasingly large group using acute care facilities yet the nature of the care is often not conducive to their personal needs, wellbeing and recovery. This research explored how a structured intervention (called the KT Toolkit) could help frontline clinical staff improve the care for older people going through one acute hospital setting in South Australia. Methods/Design: The case study approach used draws on the overarching framework of realist evaluation, a methodology designed to test, refine and explain what is happening in complex situations. Seven parallel teams within the organisation selected one discrete clinical area each for improvement through the introduction of evidence based practice guidelines. Each improvement team’s progress was recorded using multiple data sources including ethnographic observations, semi structured interviews, document reviews and other routinely collected data on nursing care. Each of the seven journeys was analysed and synthesised according to the principles of realist evaluation where the role of the researchers (and stakeholders) is to elucidate what things work for which teams in what particular circumstances thus arriving at a set of explanatory statements. Results: Four broad mechanisms appeared to be affecting the way improvements were being introduced into the clinical areas by the seven different teams: building on existing structures and support; optimising existing human potential; focus on the older person and on-going support through facilitation. Within these mechanisms a range of different actions and behaviours were noted but collectively the teams were able to show how these mechanisms enabled them to make progress in improving discrete aspects of care for their older patients. Conclusions: The use of realist evaluation as the overarching methodological framework enabled the research team to document and interpret the complex interactions happening at the level of everyday practice. Such interpretations enabled the research team to engage the clinical teams and work with them on on-going improvements. We found that even trying to improve the so-called simplest of aspects of care (e.g. weighing patients as part of nutritional care) was fraught with challenges. Also, our use of the realist method raised a number of theoretical and methodological questions that need further refining and in particular how realist evaluation relates to knowledge translation (KT) conceptual frameworks.Alison Kitson, Rick Wiechula, Kathryn Zeitz, Danni Marcoionni, Tammy Page and Heidi Silversto

Modeling healthcare authorization and claim submissions using the openEHR dual-model approach

<p>Abstract</p> <p>Background</p> <p>The TISS standard is a set of mandatory forms and electronic messages for healthcare authorization and claim submissions among healthcare plans and providers in Brazil. It is not based on formal models as the new generation of health informatics standards suggests. The objective of this paper is to model the TISS in terms of the openEHR archetype-based approach and integrate it into a patient-centered EHR architecture.</p> <p>Methods</p> <p>Three approaches were adopted to model TISS. In the first approach, a set of archetypes was designed using ENTRY subclasses. In the second one, a set of archetypes was designed using exclusively ADMIN_ENTRY and CLUSTERs as their root classes. In the third approach, the openEHR ADMIN_ENTRY is extended with classes designed for authorization and claim submissions, and an ISM_TRANSITION attribute is added to the COMPOSITION class. Another set of archetypes was designed based on this model. For all three approaches, templates were designed to represent the TISS forms.</p> <p>Results</p> <p>The archetypes based on the openEHR RM (Reference Model) can represent all TISS data structures. The extended model adds subclasses and an attribute to the COMPOSITION class to represent information on authorization and claim submissions. The archetypes based on all three approaches have similar structures, although rooted in different classes. The extended openEHR RM model is more semantically aligned with the concepts involved in a claim submission, but may disrupt interoperability with other systems and the current tools must be adapted to deal with it.</p> <p>Conclusions</p> <p>Modeling the TISS standard by means of the openEHR approach makes it aligned with ISO recommendations and provides a solid foundation on which the TISS can evolve. Although there are few administrative archetypes available, the openEHR RM is expressive enough to represent the TISS standard. This paper focuses on the TISS but its results may be extended to other billing processes. A complete communication architecture to simulate the exchange of TISS data between systems according to the openEHR approach still needs to be designed and implemented.</p

Citywide Trauma Experience in Mwanza, Tanzania: A Need for Urgent Intervention.

Trauma remains a leading cause of morbidity and mortality in resource limited countries. There is paucity of published reports on trauma care in Tanzania, particularly the study area. This study was carried out to describe our experiences in trauma management outlining the etiological spectrum, injury characteristics and treatment outcome of trauma patients at our local setting and compare our results with those from other centers in the world. A descriptive prospective study of trauma patients was conducted at Bugando Medical Centre from April 2010 to March 2012. Statistical data analysis was done using SPSS software version 17.0. A total of 5672 trauma patients were enrolled in the study. The male to female ratio was 2.3: 1. The majority of patients were in the 2nd decade of life. Road traffic accident was the most common cause of trauma accounting for 60.7% of cases. The majority of patients (76.6%) sustained blunt injuries. Musculoskeletal (68.5%) and head/neck (52.6%) were the most frequent body region injured. Soft tissue injuries (open wounds) and fractures were the most common injuries accounting for 82.8% and 76.8% respectively. Majority of patients (74.4%) were treated surgically with wound debridement (94.0%) being the most frequently performed procedure. Postoperative complications were recorded in 31.5% of cases.The overall median duration of hospitalization was 26 days (range 1 day to 144 days). Mortality rate was 16.7%. Patients who had polytrauma, burn injuries and those who had tetanus and long bone fractures stayed longer in the hospital and this was statistically significant (P < 0.001), whereas the age > 65 years, severe trauma, admission Systolic Blood Pressure < 90 mmHg, presence of tetanus, severe head injury, the duration of loss of consciousness, the need for intensive care unit admission and finding of space occupying lesion on CT scan of the brain significantly influenced mortality (P < 0.001). Trauma resulting from road traffic accidents remains a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of road traffic accidents is necessary to reduce the incidence of trauma in this region

SmoothCache: HTTP-Live Streaming Goes Peer-to-Peer

Part 1: Video StreamingInternational audienceIn this paper, we present SmoothCache, a peer-to-peer live video streaming (P2PLS) system. The novelty of SmoothCache is threefold: i) It is the first P2PLS system that is built to support the relatively-new approach of using HTTP as the transport protocol for live content, ii) The system supports both single and multi-bitrate streaming modes of operation, and iii) In Smoothcache, we make use of recent advances in application-layer dynamic congestion control to manage priorities of transfers according to their urgency. We start by explaining why the HTTP live streaming semantics render many of the existing assumptions used in P2PLS protocols obsolete. Afterwards, we present our design starting with a baseline P2P caching model. We, then, show a number of optimizations related to aspects such as neighborhood management, uploader selection and proactive caching. Finally, we present our evaluation conducted on a real yet instrumented test network. Our results show that we can achieve substantial traffic savings on the source of the stream without major degradation in user experience

Improving the fundamentals of care for older people in the acute hospital setting: facilitating practice improvement using a Knowledge Translation Toolkit

This paper reports on a structured facilitation program where seven interdisciplinary teams conducted projects aimed at improving the care of the older person in the acute sector. Aims: To develop and implement a structured intervention known as the Knowledge Translation (KT) Toolkit to improve the fundamentals of care for the older person in the acute care sector. Three hypotheses were tested: (i) frontline staff can be facilitated to use existing quality improvement tools and techniques and other resources (the KT Toolkit) in order to improve care of older people in the acute hospital setting; (ii) fundamental aspects of care for older people in the acute hospital setting can be improved through the introduction and use of specific evidence-based guidelines by frontline staff; and (iii) innovations can be introduced and improvements made to care within a 12-month cycle/timeframe with appropriate facilitation. Methods: Using realistic evaluation methodology the impact of a structured facilitation program (the KT Toolkit) was assessed with the aim of providing a deeper understanding of how a range of tools, techniques and strategies may be used by clinicians to improve care. The intervention comprised three elements: the facilitation team recruited for specific knowledge, skills and expertise in KT, evidence-based practice and quality and safety; the facilitation, including a structured program of education, ongoing support and communication; and finally the components of the toolkit including elements already used within the study organisation. Results: Small improvements in care were shown. The results for the individual projects varied from clarifying issues of concern and planning ongoing activities, to changing existing practices, to improving actual patient outcomes such as reducing functional decline. More importantly the study described how teams of clinicians can be facilitated using a structured program to conduct practice improvement activities with sufficient flexibility to meet the individual needs of the teams. Conclusions: The range of tools in the KT Toolkit were found to be helpful, but not all tools needed to be used to achieve successful results. Facilitation of the teams was a central feature of the KT Toolkit and allowed clinicians to retain control of their projects; however, finding the balance between structuring the process and enabling teams to maintain ownership and control was an ongoing challenge. Clinicians may not have the requisite skills and experience in basic standard setting, audit and evaluation and it was therefore important to address this throughout the project. In time this builds capacity throughout the organisation. Identifying evidence to support practice is a challenge to clinicians. Evidence-based guidelines often lack specificity and were found to be difficult to assimilate easily into everyday practice. Evidence to inform practice needs to be provided in a variety of forms and formats that allow clinicians to easily identify the source of the evidence and then develop local standards specific to their needs. The work that began with this project will continue – all teams felt that the work was only starting rather than concluding. This created momentum, motivation and greater ownership of improvements at local level.Rick Wiechula, Alison Kitson, Danni Marcoionni, Tammy Page, Kathryn Zeitz and Heidi Silversto