Recommended content of referral letters from general practitioners to specialised mental health care: a qualitative multi-perspective study

Background: In most Western countries, the referral letter forms the basis for establishing the priority of patients for specialised health care and for the coordination of care between the services. To be able to define the quality of referral letters, the potential impact of the quality on the organisation of care, and to improve the quality of the letters, we need a multidimensional definition of the ideal content. The study’s aim was to explore what information is seen as most important and should be included in referral letters from primary care to specialised mental health care to facilitate prioritisation and planning of treatment and follow-up of the patients. Methods: Based on purposive sampling, four mixed discussion groups, which included general practitioners, mental health nurses from primary health care, psychiatrists and psychologists from specialised mental health care, managers and patient representatives, were formed; they were asked to identify the information they considered important in a mental health referral letter. In line with the Delphi technique, the importance of the themes was later individually rated by the participants. The study was conducted within The Western Norway Regional Health Authority.Results: The four groups identified 174 information themes. After excluding themes that were assessed as duplicates, replaceable or less important, 40 themes were suggested, organised in seven units. A set of check-off points of essential information is recommended as an introduction in the referral letter. Conclusion: Compared with general guidelines and guidelines for somatic care, the results of this study suggest that the referral letter to specialised mental health care should have a larger emphasis on the overall treatment plan, on the specific role of specialised health care in the continuum of care, and on patient involvement. Further research should evaluate the validity of these findings for other patient groups in need of integrated care and investigate how the quality of referral letters affects patient-related and organisational outcomes

Co-design for implementing patient participation in hospital services : a discussion paper

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Adherence to guidelines for the management of donors after brain death

Purpose: Guideline adherence for the management of a donor after brain death (DBD) is largely unknown. This study aimed to perform an importance-performance analysis of prioritized key interventions (KIs) by linking guideline adherence rates to expert consensus ratings for the management of a DBD. Materials and methods: This observational, cross-sectional multicenter study was performed in 21 Belgian ICUs. A retrospective review of patient records of adult utilized DBDs between 2013 and 2016 used 67 KIs to describe adherence to guidelines. Results: A total of 296 patients were included. Thirty-five of 67 KIs had a high level of adherence congruent to a high expert panel rating of importance. Nineteen of 67 KIs had a low level of adherence in spite of a high level of importance according to expert consensus. However, inadequate documentation proved an important issue, hampering true guideline adherence assessment. Adherence ranged between 3 and 100% for single KI items and on average, patients received 72% of the integrated expert panel recommended care set. Conclusions: Guideline adherence to an expert panel predefined care set in DBD donor management proved moderate leaving substantial room for improvement. An importance-performance analysis can be used to improve implementation and documentation of guidelines

Collaborative approach to Optimise MEdication use for Older people in Nursing homes (COME-ON): study protocol of a cluster controlled trial

BACKGROUND: Ageing has become a worldwide reality and presents new challenges for the health-care system. Research has shown that potentially inappropriate prescribing, both potentially inappropriate medications and potentially prescribing omissions, is highly prevalent in older people, especially in the nursing home setting. The presence of potentially inappropriate medications/potentially prescribing omissions is associated with adverse drug events, hospitalisations, mortality and health-care costs. The Collaborative approach to Optimise MEdication use for Older people in Nursing homes (COME-ON) study aims to evaluate the effect of a complex, multifaceted intervention, including interdisciplinary case conferences, on the appropriateness of prescribing of medicines for older people in Belgian nursing homes. METHODS/DESIGN: A multicentre cluster-controlled trial is set up in 63 Belgian nursing homes (30 intervention; 33 control). In each of these nursing homes, 35 residents (≥65 years) are selected for participation. The complex, multifaceted intervention comprises (i) health-care professional education and training, (ii) local concertation (discussion on the appropriate use of at least one medication class at the level of the nursing home) and (iii) repeated interdisciplinary case conferences between general practitioner, nurse and pharmacist to perform medication review for each included nursing home resident. The control group works as usual. The study period lasts 15 months. The primary outcome measures relate to the appropriateness of prescribing and are defined as (1) among residents who had at least one potentially inappropriate medication/potentially prescribing omission at baseline, the proportion of them for whom there is a decrease of at least one of these potentially inappropriate medications/potentially prescribing omissions at the end of study, and (2) among all residents, the proportion of them for whom at least one new potentially inappropriate medication/potentially prescribing omission is present at the end of the study, compared to baseline. The secondary outcome measures include individual components of appropriateness of prescribing, medication use, outcomes of the case conferences, clinical outcomes and costs. A process evaluation (focusing on implementation, causal mechanisms and contextual factors) will be conducted alongside the study. DISCUSSION: The COME-ON study will contribute to a growing body of knowledge concerning the effect of complex interventions on the use of medicines in the nursing home setting, and on factors influencing their effect. The results will inform policymakers on strategies to implement in the near future. TRIAL REGISTRATION: Current Controlled Trials ISRCTN66138978

Intraclass correlation coefficients for cluster randomized trials in care pathways and usual care: hospital treatment for heart failure.

BACKGROUND: Cluster randomized trials are increasingly being used in healthcare evaluation to show the effectiveness of a specific intervention. Care pathways (CPs) are becoming a popular tool to improve the quality of health-care services provided to heart failure patients. In order to perform a well-designed cluster randomized trial to demonstrate the effectiveness of Usual care (UC) and CP in heart failure treatment, the intraclass correlation coefficient (ICC) should be available before conducting a trial to estimate the required sample size. This study reports ICCs for both demographical and outcome variables from cluster randomized trials of heart failure patients in UC and care pathways. METHODS: To calculate the degree of within-cluster dependence, the ICC and associated 95% confidence interval were calculated by a method based on analysis of variance. All analyses were performed in R software version 2.15.1. RESULTS: ICCs for baseline characteristics ranged from 0.025 to 0.058. The median value and interquartile range was 0.043 [0.026-0.052] for ICCs of baseline characteristics. Among baseline characteristics, the highest ICCs were found for admission by referral or admission from home (ICC = 0.058) and the disease severity at admission (ICC = 0.046). Corresponding ICCs for appropriateness of the stay, length of stay and hospitalization cost were 0.069, 0.063, and 0.001 in CP group and 0.203, 0.020, 0.046 for usual care, respectively. CONCLUSION: Reported values of ICCs from present care pathway trial and UC results for some common outcomes will be helpful for estimating sample size in future clustered randomized heart failure trials, in particular for the evaluation of care pathways

Probing polyoxometalate-protein interactions using molecular dynamics simulations

The molecular interactions between the Ce(IV)-substituted Keggin anion [PW11O39Ce(OH2)4]3- (CeK) and hen egg white lysozyme (HEWL), was investigated by molecular dynamics (MD) simulations. We compared the analysis of CeK with the Ce(IV)-substituted Keggin dimer [(PW11O39)2Ce]10- (CeK2) and the Zr(IV)-substituted Lindqvist anion [W5O18Zr(OH2)(OH)]3- (ZrL) in order to understand how POM features such as the shape, the size, the charge or the type of incorporated metal ion influence the POM···protein interactions. Simulations revealed two regions of the protein, in which the CeK anion interacts strongly: the cationic sites formed by Arg21 on one hand and by Arg45 and Arg68 on the other. The two sites can be related with the observed selectivity in the hydrolytic cleavage of HEWL. The POMs chiefly interact with the side chains of the positively charged (arginines and lysines) and the polar uncharged (tyrosines, serines and aspargines) residues via electrostatic attraction and hydrogen bonding with the oxygens of the POM framework. The CeK anion shows higher protein affinity than the CeK2 and ZrL anions, because it is less hydrophilic and it has the right size and shape for stablishing interactions with several residues simultaneously. The larger and more negatively charged CeK2 anion has a high solvent-accessible surface, which is sub-optimal for the interaction, while the smaller ZrL anion is highly hydrophilic and it cannot interact simultaneously with several residues so efficiently

Effectiveness of Platform-Based Robot-Assisted Rehabilitation for Musculoskeletal or Neurologic Injuries: A Systematic Review

During the last ten years the use of robotic-assisted rehabilitation has increased significantly. Compared with traditional care, robotic rehabilitation has several potential advantages. Platform-based robotic rehabilitation can help patients recover from musculoskeletal and neurological conditions. Evidence on how platform-based robotic technologies can positively impact on disability recovery is still lacking, and it is unclear which intervention is most effective in individual cases. This systematic review aims to evaluate the effectiveness of platform-based robotic rehabilitation for individuals with musculoskeletal or neurological injuries. Thirty-eight studies met the inclusion criteria and evaluated the efficacy of platform-based rehabilitation robots. Our findings showed that rehabilitation with platform-based robots produced some encouraging results. Among the platform-based robots studied, the VR-based Rutgers Ankle and the Hunova were found to be the most effective robots for the rehabilitation of patients with neurological conditions (stroke, spinal cord injury, Parkinson’s disease) and various musculoskeletal ankle injuries. Our results were drawn mainly from studies with low-level evidence, and we think that our conclusions should be taken with caution to some extent and that further studies are needed to better evaluate the effectiveness of platform-based robotic rehabilitation devices

Healthcare Students and Medical Residents as Second Victims: A Cross-Sectional Study

Background: The term second victim (SV) describes healthcare professionals who remain traumatized after being involved in a patient safety incident (PSI). They can experience various emotional, psychological, and physical symptoms. The phenomenon is quite common; it has been estimated that half of hospital workers will be an SV at least once in their career. Because recent literature has reported high prevalence (>30%) among nursing students, we studied the phenomenon among the whole population of healthcare students. Methods: We conducted a cross-sectional study with an online questionnaire among nursing students, medical students, and resident physicians at the teaching hospital of the University of the Piemonte Orientale located in Novara, Italy. The study included 387 individuals: 128 nursing students, 174 medical students, and 85 residents. Results: We observed an overall PSI prevalence rate of 25.58% (lowest in medical students, 14.37%; highest in residents, 43.53%). Of these, 62.63% experienced symptoms typical of an SV. The most common temporary symptom was the feeling of working badly (51.52%), whereas the most common lasting symptom was hypervigilance (51.52%). Notably, none of the resident physicians involved in a PSI spoke to the patient or the patient's relatives. Conclusion: Our findings highlighted the risk incurred by healthcare students of becoming an SV, with a possible significant impact on their future professional and personal lives. Therefore, we suggest that academic institutions should play a more proactive role in providing support to those involved in a PSI

Eight-step method to build the clinical content of an evidence-based care pathway: the case for COPD exacerbation

Abstract Background Optimization of the clinical care process by integration of evidence-based knowledge is one of the active components in care pathways. When studying the impact of a care pathway by using a cluster-randomized design, standardization of the care pathway intervention is crucial. This methodology paper describes the development of the clinical content of an evidence-based care pathway for in-hospital management of chronic obstructive pulmonary disease (COPD) exacerbation in the context of a cluster-randomized controlled trial (cRCT) on care pathway effectiveness. Methods The clinical content of a care pathway for COPD exacerbation was developed based on recognized process design and guideline development methods. Subsequently, based on the COPD case study, a generalized eight-step method was designed to support the development of the clinical content of an evidence-based care pathway. Results A set of 38 evidence-based key interventions and a set of 24 process and 15 outcome indicators were developed in eight different steps. Nine Belgian multidisciplinary teams piloted both the set of key interventions and indicators. The key intervention set was judged by the teams as being valid and clinically applicable. In addition, the pilot study showed that the indicators were feasible for the involved clinicians and patients. Conclusions The set of 38 key interventions and the set of process and outcome indicators were found to be appropriate for the development and standardization of the clinical content of the COPD care pathway in the context of a cRCT on pathway effectiveness. The developed eight-step method may facilitate multidisciplinary teams caring for other patient populations in designing the clinical content of their future care pathways.</p

Psychological impact and recovery after involvement in a patient safety incident: A repeated measures analysis

OBJECTIVE: To examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives. DESIGN: Cross-sectional, retrospective surveys of physicians, midwives and nurses. SETTING: 33 Belgian hospitals. PARTICIPANTS: 913 clinicians (186 physicians, 682 nurses, 45 midwives) involved in a patient safety incident. MAIN OUTCOME MEASURES: The Impact of Event Scale was used to retrospectively measure psychological impact of the safety incident at the time of the event and compare it with psychological impact at the time of the survey. RESULTS: Individual, situational as well as organisational aspects influenced psychological impact and recovery of a patient safety incident. Psychological impact is higher when the degree of harm for the patient is more severe, when healthcare professionals feel responsible for the incident and among female healthcare professionals. Impact of degree of harm differed across clinicians. Psychological impact is lower among more optimistic professionals. Overall, impact decreased significantly over time. This effect was more pronounced for women and for those who feel responsible for the incident. The longer ago the incident took place, the stronger impact had decreased. Also, higher psychological impact is related with the use of a more active coping and planning coping strategy, and is unrelated to support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact. No associations were found with job experience and resilience of the health professional, the presence of a second victim support team or guideline and working in a learning culture. CONCLUSIONS: Healthcare organisations should anticipate on providing their staff appropriate and timely support structures that are tailored to the healthcare professional involved in the incident and to the specific situation of the incident