Falls Prevention for Older Adults.

This article summarizes a 2022 clinical practice guideline on falls prevention and management in older adults from the World Falls Guidelines Initiative.

Optimization of Patient Progression in a New Era: A Comprehensive Framework.

PURPOSE/OBJECTIVES: The onset of the coronavirus disease 2019 pandemic increased the demand for inpatient services and led to widespread staffing shortages in the acute and post-acute setting, contributing to delayed inpatient throughput and leading to capacity crises. Novel strategies are needed to facilitate the efficient progression of hospitalized patients when medically ready for lower levels of care. The authors have developed a foundational strategic framework for patient progression to ensure capture of patient progression data, enhance efficiency, and optimal utilization of post-acute resources in increasingly complex and resource-constrained acute and post-acute environments. PRIMARY PRACTICE SETTINGS: Interventions were implemented, and metrics of success tracked as part of an overarching framework to test new models of care or optimize existing assets related to barriers to patient progression. Brigham and Women's Hospital (BWH) and Brigham and Women's Faulkner Hospital (BWFH) comprise an academic medical center and a community hospital, respectively, that are affiliated with Massachusetts General Brigham (MGB), a nonprofit health care system in Massachusetts. Key interventions include (1) screening to prioritize patients needing case management services through a modified early screening for discharge planning tool and process; (2) communicating, documenting, identifying patient progression status, barriers to discharge and post-acute needs through interdisciplinary care optimization rounds, a novel tool in the electronic health record, and an associated dashboard; (3) managing active high-risk patients through a novel complex care team and post-acute strategy development; (4) developing novel transportation and hospice pathways; and (5) establishing community hospital repatriation and a physical therapy "Why Not Home" campaign. FINDINGS: Key metrics of success were (1) modified discharge planning tool resulting in screening out low-risk patients (53%) and impacting length of stay (0.55-day reduction, p = .083) during a 3-month intervention versus control study; (2) documentation adherence in more than 98% of patients 10 months postimplementation; (3) complex care team achieving a 2.5% reduction in Case Mix Index-adjusted length of stay 6 months postimplementation; (4) use of care van offsetting ambulance/chair car in 10% of cases, and earlier discharge time/length of stay in 21% of cases 3 months postimplementation; and (5) implementation of community repatriation impacting delay days to discharge (10-month pilot, 40 patients accounting for 1,000 delay days). CONCLUSIONS: Implementation of a novel comprehensive framework focusing on optimizing patient progression resulted in increased operational efficiency and positively impacted length of stay at our academic and community hospitals. Additional study is actively ongoing to understand long-term benefit of the innovations that the authors have developed. Further interventions are needed to wholly mitigate evolving capacity challenges in the acute and post-acute settings. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The authors' implementation of the Brigham framework for progression demonstrates that innovative approaches to case management can help address the evolving challenges in care transitions planning. Notable opportunities include approaches that empower case managers as multidisciplinary team leaders, improve workflow, utilize patient progression data, prioritize patients with complex care needs support key patient populations, and promote post-acute collaboration.

Exploring Models of Exposure to Primary Care Careers in Training: a Narrative Review.

Multiple models of clinical exposure to primary care exist within undergraduate medical education (UME) and graduate medical education (GME). In this narrative review, we explore the evidence behind these different models of exposure, their alignment with positive promoters of primary care careers, and the pros and cons of each. Without positive exposure to primary care during training, sustaining the future primary care work force becomes increasingly challenging. Here, we explore multiple models of clinical exposure in UME, including longitudinal integrated clerkships, primary care tracks, and primary care clerkships. Within GME, we will review the impact of primary care tracks, Area Health Education Centers, block scheduling models, and continuity clinic scheduling models. The goal of this narrative review is to allow educators to think broadly and intentionally about the array of models to develop positive primary care experiences and perceptions in training, ultimately sustaining the primary care workforce.

Healthcare disparities: patients' perspectives on barriers to joint replacement.

OBJECTIVE: Racial and ethnic disparities in arthroplasty utilization are evident, but the reasons are not known. We aimed to identify concerns that may contribute to barriers to arthroplasty from the patient's perspective. METHODS: We identified patients' concerns about arthroplasty by performing a mixed methods study. Themes identified during semi-structured interviews with Black and Hispanic patients with advanced symptomatic hip or knee arthritis were used to develop a questionnaire to quantify and prioritize their concerns. Multiple linear and logistic regression analyses were conducted to determine the association between race/ethnicity and the importance of each theme. Models were adjusted for sex, insurance, education, HOOS, JR/KOOS, JR, and discussion of joint replacement with a doctor. RESULTS: Interviews with eight participants reached saturation and provided five themes used to develop a survey answered by 738 (24%) participants; 75.5% White, 10.3% Black, 8.7% Hispanic, 3.9% Asian/Other. Responses were significantly different between groups (p < 0.05). Themes identified were "Trust in the surgeon" "Recovery", "Cost/Insurance", "Surgical outcome", and "Personal suitability/timing". Compared to Whites, Blacks were two-fold, Hispanics four-fold more likely to rate "Trust in the surgeon" as very/extremely important. Blacks were almost three times and Hispanics over six times more likely to rate "Recovery" as very/extremely important. CONCLUSION: We identified factors of importance to patients that may contribute to barriers to arthroplasty, with marked differences between Blacks, Hispanics, and Whites.

Diagnosis and Management of Nonalcoholic Fatty Liver Disease.

This JAMA Clinical Guidelines Synopsis summarizes the American Association of Clinical Endocrinology's 2022 clinical practice guideline for diagnosis and management of nonalcoholic fatty liver disease.

P29-A135†Impact of COVID-19 on corneal donation and transplantation in Hong Kong.

PURPOSE: With many health and policy issues arising from COVID-19, the Hospital Authority Eye Bank of Hong Kong encountered challenges related to ocular donor suitability and availability. This review aims to analyse the impact of a global pandemic on corneal donation and transplantation in 2020 and 2021, compared to the pre-COVID period in 2019. METHODS: This cohort study evaluated data collected from the Hospital Authority Eye Bank from January 2019 to December 2021. The number of corneas harvested, including voluntary donations initiated by the deceased's relatives and approached cases by Eye Donation Coordinators, tissue distributed, transplanted and disposed, the reason for disposal as well as the usage of the transplanted corneas in 2020 and 2021 were compared to the pre-COVID period of 2019. RESULTS: The number of corneas harvested dropped by 17.6% in 2020 compared to the pre-COVID period of 2019, and rose almost back to baseline in 2021. However, despite having near-normal number of harvested corneas in 2021, the number of corneal transplants using fresh corneas were still reduced by 30% in 2020 and 27% 2021. The observation can be explained by the seven-fold increment in disposal due to suboptimal quality from a cancer donor in 2021. The proportion of corneas used for optical, therapeutic and tectonic purposes remained stable throughout the three years. CONCLUSION: COVID-19 yielded brief periods of service interruption and reduced number of eligible donors, leading to a noticeable rise in solicitation from cancer donors in 2021. The pandemic resulted in a longer corneal transplant waiting time. Nevertheless, The proportion of different corneal transplantation remained stable, with even the development in new techniques such as Descemet's Membrane Endothelial Keratoplasty and enhancement in services such as provision of ultra-fresh Keratolimbal allografts despite the limitations in the COVID-19 era.

Development and Piloting of a Community-Partnered Heart Failure Training Course for Home Health Care Workers.

BACKGROUND: Despite their unique contributions to heart failure (HF) care, home healthcare workers (HHWs) have unmet educational needs and many lack HF caregiving self-efficacy. To address this, we used a community-partnered approach to develop and pilot a HF training course for HHWs. METHODS: We partnered with the Training and Employment Fund, a benefit fund of the largest healthcare union in the United States, to develop a 2-hour virtual HF training course that met HHWs' job-specific needs. English and Spanish-speaking HHWs interested in HF training, with access to Zoom, were eligible. We used a mixed methods design with pre/postsurveys and semi-structured interviews to evaluate the course: (a) feasibility, (b) acceptability, and (c) effectiveness (change in knowledge [Dutch Heart Failure Knowledge Scale range 0-15] and caregiving self-efficacy [HF Caregiver Self-efficacy Scale range 0-100]). RESULTS: Of the 210 HHWs approached, 100 were eligible and agreed, and 70 enrolled. Of them, 53 (employed by 15 different home care agencies) participated. Posttraining data showed significant improvements (pretraining mean [SD] versus posttraining mean [SD]; P value) in HF knowledge (11.21 [1.90] versus 12.21 [1.85]; P=0.0000) and HF caregiving self-efficacy (75.21 [16.57] versus 82.29 [16.49]; P=0.0017); the greatest gains occurred among those with the lowest pre-training scores. Participants found the course engaging, technically feasible, and highly relevant to their scope of care. CONCLUSIONS: We developed and piloted the first HF training course for HHWs, which was feasible, acceptable, and improved their HF knowledge and caregiving self-efficacy. Our findings warrant scalability to the workforce at large with a train-the-trainer model.

Health Priorities of Multi-Morbid Ambulatory Patients in New York City During the COVID-19 Pandemic: A Qualitative Analysis.

During the COVID-19 pandemic, adults with chronic conditions delayed or avoided seeking preventative and general medical care, leading to adverse consequences for morbidity and mortality. In order to bring patients back into care, we, in this qualitative study, sought to understand the foremost health-related needs of our multi-morbid ambulatory patients to inform future outreach interventions. Via a telephone-based survey of our high-risk patients, defined using a validated EPIC risk model for hospitalization and ED visits, we surveyed 214 participants an open-ended question, "What is your top health concern that you would like to speak with a doctor or nurse about". We found 4 major themes: 1) primary care matters, 2) disruptions in health care, 3) COVID-19's impact on physical and mental health, and 4) amplified social vulnerabilities. Our results suggest that interventions that reduce barriers to preventative services and disruptions to healthcare delivery are needed.

Factors Associated with Never Having Had A Video Visit.

INTRODUCTION: Disparities in access to video-visit services have been described during the COVID-19 pandemic. Thus, we aimed to examine factors associated with not having a video-visit among a medically high-risk ambulatory population. METHODS: In this cross-sectional study, our telephone-based survey was designed to understand the health-related challenges, social needs, and access to and attitudes toward video-visit. RESULTS: In the multivariable analysis, having fewer symptoms unrelated to COVID, more barriers to medications, and less confidence with video-visit software were significantly associated with an increased prevalence of not having a video-visit. CONCLUSIONS: Our findings suggest that additional efforts are needed to eliminate disparate video-visit use.

Effects of Safety Zone Implementation on Perceptions of Safety and Well-being When Caring for COVID-19 Patients.

BACKGROUND: In March 2020, the caseload of patients positive for COVID-19 in hospitals began increasing rapidly, creating fear and anxiety among health care workers and concern about supplies of personal protective equipment. OBJECTIVES: To determine if implementing safety zones improves the perceptions of safety, well-being, workflow, and teamwork among hospital staff caring for patients during a pandemic. METHODS: A safety zone process was implemented to designate levels of contamination risk and appropriate activities for certain areas. Zones were designated as hot (highest risk), warm (moderate risk), or cold (lowest risk). Caregivers working in the safety zones were invited to complete a survey regarding their perceptions of safety, caregiver well-being, workflow, and teamwork. Each question was asked twice to obtain caregiver opinions for the periods before and after implementation of the zones. RESULTS: Significant improvements were seen in perceptions of caregiver safety (P < .001) and collaboration within a multidisciplinary staff (P < .001). Significant reductions in perceived staff fatigue (P = .03), perceived cross contamination (P < .001), anxiety (P < .001), and fear of exposure (P < .001) were also seen. Teamwork (P = .23) and workflow (P = .69) were not significantly affected. CONCLUSIONS: Safety zone implementation improved caregivers' perceptions of their safety, their well-being, and collaboration within the multidisciplinary staff but did not improve their perceptions of teamwork or workflow.

Observational bias within a hospital-wide hand hygiene program.

We assessed the extent to which healthcare workers report more favorable hand hygiene rates when observing members of their own professional group versus other groups' observations of them. Healthcare workers consistently reported higher compliance rates for their own group compared to others' observations of them (97 vs 92%; P ≤ .001).

Eliciting the educational priorities of home care workers caring for adults with heart failure.

BACKGROUND: Although home care workers (HCWs) are increasingly caring for adults with heart failure (HF), many feel unprepared and lack HF training. To serve as the foundation for a future educational intervention, we aimed to elicit HCWs' HF educational needs. METHODS: We partnered with the largest healthcare union in the US to recruit 41 HCWs employed by 17 home care agencies. Using the nominal group technique, we asked HCWs to respond to three questions: When caring for an HF patient: (1) What information do you want? (2) What symptoms worry you? (3) What situations do you struggle with? Participants ranked their responses by priority. Data were consolidated by question. RESULTS: For question 1, participants ranked HF signs and symptoms most highly, followed by HF treatment and medications. For question 2, chest pain was most worrisome, followed by neurologic changes and shortness of breath. For question 3, participants struggled with encouraging patients to follow a heart-specific diet. CONCLUSIONS: HCWs expressed a need to learn more about signs and symptoms of HF and ways to assist patients with HF self-care. These findings can inform the development of an HF training program for HCWs that specifically addresses their expressed needs.

Addressing Psychosocial Stressors through a Community-Academic Partnership between a Museum and a Federally Qualified Health Center: A Qualitative Study.

Psychosocial stressors are prevalent and linked to worse health outcomes, but are less frequently addressed than physically apparent medical conditions at primary care visits. Through a community-academic partnership between an art museum and a federally qualified health center, we developed an innovative museum-based intervention and evaluated its feasibility and acceptability among diverse, underserved patients and its perceived effects on psychosocial stressors. Guided by experiential learning and constructivist approaches, the intervention consisted of a single, three-hour session that incorporated group discussions and interactive components, including art-viewing, sketching, and object-handling. We used post-intervention focus groups to elicit feedback qualitatively. From July 2017 to January 2018, 25 patients participated. Focus groups revealed that the intervention exhibited therapeutic qualities, fostered self-reflection, catalyzed social connectivity, and functioned as a gateway to community resources. These findings can guide future research and development of community-based interventions to target the growing burden of psychosocial stressors among the underserved.

Eliciting the educational needs and priorities of home care workers on end-of-life care for patients with heart failure using nominal group technique.

BACKGROUND: Home care workers, as paid caregivers, assist with many aspects of home-based heart failure care. However, most home care workers do not receive systematic training on end-of-life care for heart failure patients. AIM: To elicit the educational needs and priorities of home care workers caring for community- dwelling adults with heart failure at the end-of-life. DESIGN: Nominal group technique involving a semi-quantitative structured group process and point rating system was used to designate the importance of priorities elicited from home care workers. Individual responses to the question, "If you have ever cared for a heart failure patient who was dying (or receiving end-of-life care on hospice), what are some of the challenges you faced?", were aggregated into categories using directed content analysis methods. SETTING/PARTICIPANTS: Forty-one home care workers were recruited from a non-profit training and education organization in New York City. RESULTS: Individual responses to the question were aggregated into five categories: (1) how to cope and grieve; (2) assisting patients with behavior changes, (3) supporting patients to improve their quality of life, (4) assisting patients with physical symptom management, and (5) symptom recognition and assessment. CONCLUSIONS: Our findings confirm the need for the formal development and evaluation of an educational program for home care workers to improve the care of heart failure patients at the end-of-life. There is also a need for research on integrating home care workers into the interprofessional healthcare team to support optimal health outcomes for patients with heart failure.

Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

OBJECTIVE: To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database. STUDY DESIGN: Retrospective cohort study. SETTING: The study was conducted using the Pediatric Health Information System (PHIS) database. METHODS: Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region. RESULTS: Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 (P < .001). Older age (≥12 vs <5 years old: adjusted odds ratio [aOR] 3.17; 95% CI: 2.86, 3.52), male sex (aOR 1.11; 95% CI: 1.05, 1.17), medical comorbidities (aOR 1.18; 95% CI: 1.08, 1.29), recurrent tonsillitis (aOR 1.15; 95% CI: 1.07, 1.24), and intensive care unit admission (aOR 1.74; 95% CI: 1.55, 1.95) were significantly associated with an increased risk of PTH. Use of ibuprofen (aOR 1.36; 95% CI: 1.22, 1.52), ketorolac (aOR 1.39; 95% CI: 1.14, 1.69), anticonvulsant (aOR 1.23; 95% CI: 1.03, 1.76), and antidepressants (aOR 1.35; 95% CI: 1.03, 1.76) were also associated with an increased risk of PTH. The need for blood transfusion was 2.1% (181/8735). CONCLUSION: The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.

Perioperative pain control and tympanostomy tube outcomes.

OBJECTIVE: To evaluate perioperative pain management regimens as they relate to tympanostomy tube outcomes. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral children's hospital. SUBJECTS: and Methods: The medical records of patients ≤18 years old who underwent tympanostomy tube placement were reviewed for indications, perioperative pain medications, post anesthesia recovery unit (PACU) measures, and tympanostomy tube occlusion rates. RESULTS: Four hundred and fifty-five patients met inclusion criteria. Median age was 1.7 years (interquartile range: 1.2-3.3 years). Recurrent acute otitis media (n = 239, 52.5%) was the most common indication. All patients were American Society of Anesthesiologists (ASA) class 1 (n = 244, 58.1%) or 2 (n = 176, 41.9%). Fentanyl alone (n = 321, 70.6%) was the most common intraoperative analgesic administered followed by ketorolac alone (n = 40, 8.8%), and fentanyl and ketorolac together (n = 58, 12.8%). There was no significant difference in FLACC pain score at discharge and recovery time (minutes) also did not differ by intraoperative analgesia group (34.3 ± 15.2 for fentanyl; 36.2 ± 13.0 for ketorolac; 31.0 ± 12.5 for fentanyl and ketorolac together). Forty nine patients (11.6%) had an occluded tympanostomy tube at follow-up. Patients ≤1 year of age had a significantly higher risk of tube occlusion than patients >1 year of age (23.7% vs. 8.9%; p < 0.001). There was no significant difference in tube occlusion rates based on indication for tube placement, history of tube placement, intraoperative findings, or intraoperative pain regimen. CONCLUSIONS: Ketorolac is a reasonable non-narcotic alternative to fentanyl which provides equal pain control and does not increase tube occlusion rates.

Understanding the Workflow of Home Health Care for Patients with Heart Failure: Challenges and Opportunities.

BACKGROUND: Readmission rates are high among heart failure (HF) patients who require home health care (HHC) after hospitalization. Although HF patients who require HHC are often sicker than those who do not, HHC delivery itself may also be suboptimal. OBJECTIVE: We aimed to describe the workflow of HHC among adults discharged home after a HF hospitalization, including the roles of various stakeholders, and to determine where along these workflow challenges and opportunities for improvement exist. DESIGN AND PARTICIPANTS: In this qualitative study, we used purposeful sampling to approach and recruit a variety of key stakeholders including home health aides, nurses, HF patients, family caregivers, physicians, social workers, home care agency leaders, and policy experts. The study took place in New York, NY, from March to October 2018. APPROACH: Using a semi-structured topic guide, we elicited participants' experiences with HHC in HF through a combination of one-on-one interviews and focus groups. Data were recorded, transcribed, and analyzed thematically. We also asked selected participants to depict in a drawing their understanding of HHC workflow after hospitalization for HF patients. We synthesized the drawings into a final image. KEY RESULTS: Study participants (N = 80) described HHC for HF patients occurring in 6 steps, with home health aides playing a main role: (1) transitioning from hospital to home; (2) recognizing clinical changes; (3) making decisions; (4) managing symptoms; (5) asking for help; and (6) calling 911. Participants identified challenges and opportunities for improvement for each step. CONCLUSIONS: Our findings suggest that HHC for HF patients occurs in discrete steps, each with different challenges. Rather than a one-size-fits-all approach, various interventions may be required to optimize HHC delivery for HF patients in the post-discharge period.

"It's Like They Forget That the Word 'Health' Is in 'Home Health Aide'": Understanding the Perspectives of Home Care Workers Who Care for Adults With Heart Failure.

Background Home care workers ( HCW s) increasingly provide long-term and posthospitalization care for community-dwelling adults with heart failure ( HF ). They observe, assist, and advise these patients, yet few studies have examined their role in HF . As the foundation for future interventions, we sought to understand the perspectives of HCW s caring for adults with HF . Methods and Results We conducted 8 focus groups in partnership with the Home Care Industry Education Fund, a benefit fund of the 1199 Service Employees International Union United Healthcare Workers East, the largest healthcare union in the United States. English- and Spanish-speaking HCW s with HF clients were eligible to participate. Data were analyzed thematically. Forty-six HCW s employed by 21 unique home care agencies participated. General and HF -specific themes emerged. Generally, HCW s (1) feel overworked and undervalued; (2) find communication and care to be fragmented; (3) are dedicated to clients and families but are caught in the middle; and, despite this, (4) love their job. With respect to HF , HCW s (1) find it frightening and unpredictable; (2) are involved in HF self-care without any HF training; and (3) find the care plan problematic. Conclusions Although frequently involved in HF self-care, most HCW s have not received HF training. In addition, many felt poorly supported by other healthcare providers and the care plan, especially when their clients' symptoms worsened. Interventions that provide HF -specific training and aim to improve communication between members of the home health care team may enhance HCW s' ability to care for adults with HF and potentially lead to better patient outcomes.

Home care workers in heart failure: a systematic review.

BACKGROUND: Home care workers (HCWs), which include home health aides and personal care aides, are increasingly used by heart failure (HF) patients for post-acute care and long-term assistance. Despite their growing presence, they have largely been left out of HF research and interventions. This systematic review was aimed to 1) describe utilization patterns of HCWs by adults with HF, 2) examine the effect of HCWs on HF outcomes, and 3) review HF interventions that involve HCWs. METHODS: Five electronic databases (Ovid MEDLINE, Ovid EMBASE, Cochrane Library [Wiley], CINAHL [EBSCO], and AgeLine [EBSCO]) were searched from inception through August 4, 2017. The yield was screened using prespecified inclusion and exclusion criteria. Two authors independently reviewed references and a third reviewer acted as an arbitrator when needed. Data were extracted from articles that met the inclusion criteria. The Downs and Black checklist was used for quality assessment. Due to study heterogeneity, a narrative synthesis was conducted. RESULTS: Of the 7,032 studies screened, 13 underwent full-text review, and six met the inclusion criteria. Two descriptive studies found that adults with HF who live alone and have functional and cognitive deficits utilize HCWs. While three retrospective cohort studies examined the association between having an HCW post-HF hospitalization and readmission rates, their findings were conflicting. One quasi-experimental study found that an HCW-delivered educational intervention improved HF patients' self-care abilities. Overall, despite some significant findings, the studies assessed were of poor-to-fair quality (Downs and Black score range: 10-16 [28 total points]), with most lacking methodological rigor. CONCLUSION: Although HCWs are quite common, the literature on these paraprofessionals in HF is limited. Given the paucity of research in this area and the low quality of studies reviewed here, additional research is warranted on the potential role of HCWs in HF self-care and on outcomes among adults with HF.