Sustaining e-health innovations in a complex hospital environment: learning through evidence.

Implementing and sustaining technological innovations in healthcare is a complex process. Commonly, innovations are abandoned due to unsuccessful attempts to sustain and scale-up post implementation. Limited information is available on what characterizes successful e-health innovations and the enabling factors that can lead to their sustainability in complex hospital environments. We present a successful implementation, sustainability and scale-up of a virtual care program consisting of three e-health applications (telemedicine, telehome monitoring, and interactive voice response) in a major cardiac care hospital in Canada. We describe their evolution and adaptation over time, present the innovative approach for their "business case" and funding that supported their implementation, and identify key factors that enabled their sustainability and success, which may inform future research and serve as a benchmark for other health care organizations. Despite resource constraints, e-health innovations can be deployed and successfully sustained in complex healthcare settings contingent key considerations: simplifying technology to make it intuitive for patients; providing significant value proposition that is research supported to influence policy changes; involving early supporters of adoption from administrative and clinical staff; engaging patients throughout the innovation cycle; and partnering with industry/technology providers.

Optimizing care of patients undergoing cardiac surgery using a digital platform and a multidisciplinary team approach.

OBJECTIVE: Restrictions to care access during the pandemic along with the increasing complexity of patients awaiting cardiac surgery provides unique challenges for care delivery. The University of Ottawa Heart Institute has developed a novel multidisciplinary digital platform, the Prehab Automated Follow-Up (AFU) Program, which delivers patient/caregiver teaching regarding risk factor mitigation, tracks patient symptoms, and screens for optimization using best practice guidelines. This study was conducted to quantify patient outcomes following initiation of the AFU Program. METHODS: Patients awaiting elective cardiac surgery are enrolled and screened via automated telephone conversation, according to best practice guidelines, and a Short Form-12 preoperative assessment. Following this screen, patients are referred for an in-person assessment by an appropriate multidisciplinary team member; namely, a diabetes specialist, physiotherapist, dietitian, smoking cessation counselor, social worker, vocational counselor, and/or psychologist. RESULTS: Since initiation in February 2021, the AFU Program has enrolled more than 1237 patients with 508 multidisciplinary team referrals prompted by the AFU screening platform. Before program initiation, there were no multidisciplinary team referrals for preoperative optimization. Compared with patients treated between February 2020 and February 2021, there was a 2.5% decrease in hospital readmission rate within 30 days of surgery, a 0.6-day shorter hospital stay, and a 2.5% decrease in surgical site infection. CONCLUSIONS: Our cardiac surgery AFU Program reduced adverse health outcomes for patients by identifying and optimizing risk factors that increased quality of patient care. The AFU Program provides patient/caregiver engagement through educational support and multidisciplinary team counseling.

IVR System Use by Patients with Heart Failure: Compliance and Services Utilization Patterns.

Heart failure (HF) is the leading cause of cardiovascular morbidity and health care utilization globally. Much of the cost for HF is related to hospitalization, strategies to decrease cost need to focus on avoiding unnecessary hospital readmission. Interactive voice response (IVR) is an automated telephony system that leverages existing telephone lines to monitor patients post-discharge, for early intervention. This study explores the pattern of IVR use by HF patients in the IVR program at the University of Ottawa Heart Institute (UOHI) and assesses IVR use by patients in relation to symptoms, compliance behavior, lifestyle, and hospital readmission. A total of 902 HF patients were considered; the mean age was 70 years, and 59.4% were male. Over a 12-week period of IVR use, there was an overall increase in medication adherence and a decrease in symptoms occurrence, weight gain and readmission rate. The highest and lowest compliance rates were associated with medication adherence and exercise, respectively. Overall, older, female patients from rural/community hospitals were more likely to complete the IVR calls, have less symptoms occurrence, comply with medications, weight, and lifestyle recommendations. The findings suggest that IVR system use can have a positive impact on HF patients' management. The increased use of IVR in remote patient monitoring will allow for a cheaper and more accessible form of home monitoring. Leveraging IVR technology to support other conditions, especially during a pandemic, may be beneficial for patients to avoid unnecessary visits to the hospital and complications due to delay in seeking care.

Derivation of Patient-Defined Adverse Cardiovascular and Noncardiovascular Events Through a Modified Delphi Process.

Importance: There is little evidence to support patient-centered outcomes in patients with cardiovascular disease. Objective: To derive patient-defined adverse cardiovascular and noncardiovascular events (PACE) through a consensus-based process. Design, Setting, and Participants: This pan-Canadian, consensus-based, qualitative study used an iterative Delphi method to achieve consensus within a 35-member panel consisting of patients with cardiovascular diseases and their caregivers and clinicians. The process included 4 rounds of online questionnaires, followed by an in-person final consensus meeting. Data analysis was performed in September 2019. Main Outcomes and Measures: Defining PACE as a 5-item composite outcome. Results: Thirty-five potential panelists consented to participate, including 11 clinicians (8 men [73%]) and 24 patients and caregivers (13 men [54%]). Twenty-nine (83%), 28 (80%), 26 (74%), and 23 (66%) of the panelists participated in each of respective the online rounds. A shortlist of 11 patient-defined items was further refined at the in-person meeting, which 20 of the panelists attended. The PACE definition that was decided through the consensus process was a composite of severe stroke necessitating hospitalization for 14 days or longer or inpatient rehabilitation, ventilator dependence, new onset or worsening heart failure, nursing home admission, or new onset dialysis. Conclusions and Relevance: This study defined PACE as a versatile, patient-centered outcome through a consensus process with input from patients, caregivers, and clinicians. Given the paucity of patient-centered outcomes in cardiovascular research, PACE may be considered as a potential outcome after methodological evaluation of its reliability.

Derivation and Validation of a Clinical Model to Predict Intensive Care Unit Length of Stay After Cardiac Surgery.

Background Across the globe, elective surgeries have been postponed to limit infectious exposure and preserve hospital capacity for coronavirus disease 2019 (COVID-19). However, the ramp down in cardiac surgery volumes may result in unintended harm to patients who are at high risk of mortality if their conditions are left untreated. To help optimize triage decisions, we derived and ambispectively validated a clinical score to predict intensive care unit length of stay after cardiac surgery. Methods and Results Following ethics approval, we derived and performed multicenter valida tion of clinical models to predict the likelihood of short (≤2 days) and prolonged intensive care unit length of stay (≥7 days) in patients aged ≥18 years, who underwent coronary artery bypass grafting and/or aortic, mitral, and tricuspid value surgery in Ontario, Canada. Multivariable logistic regression with backward variable selection was used, along with clinical judgment, in the modeling process. For the model that predicted short intensive care unit stay, the c-statistic was 0.78 in the derivation cohort and 0.71 in the validation cohort. For the model that predicted prolonged stay, c-statistic was 0.85 in the derivation and 0.78 in the validation cohort. The models, together termed the CardiOttawa LOS Score, demonstrated a high degree of accuracy during prospective testing. Conclusions Clinical judgment alone has been shown to be inaccurate in predicting postoperative intensive care unit length of stay. The CardiOttawa LOS Score performed well in prospective validation and will complement the clinician's gestalt in making more efficient resource allocation during the COVID-19 period and beyond.

A Novel Protocol for Very Early Hospital Discharge After STEMI.

Although the incidence of ST-elevation myocardial infarction (STEMI) is on the decline, management of patients who present with STEMI continues to require significant health care resources. Earlier hospital discharge in low-risk patients who present with STEMI has been an area of focus in an attempt to reduce health care costs. As a result, discharge within 48-72 hours after successful primary percutaneous coronary intervention has increasingly become routine practice. Moreover, the current COVID-19 pandemic has led to enormous pressure on health care systems to find ways to increase bed capacity, preserve resources, and reduce the risk of exposure to patients and health care workers. In response to this goal, the Ottawa Heart Institute has developed and implemented a novel Very Early Hospital Discharge (VEHD) protocol. The VEHD protocol is a simple, 4-step algorithm designed to accurately and efficiently identify low-risk STEMI patients who can be safely discharged between 20 and 36 hours after successful primary percutaneous coronary intervention. When deemed eligible for VEHD predischarge tasks are completed by the treating medical and nursing team and the patient is discharged home. Follow-up is completed remotely via virtual care (48 hours, 7 days, 30 days), and in the outpatient cardiology clinic (4-6 weeks). Amid a worldwide COVID-19 pandemic we believe the VEHD protocol is a crucial step in maintaining exceptional quality of care, in terms of patient satisfaction and clinical outcomes, while concurrently decreasing the risk of nosocomial infections, and reducing resource utilization.