Outcomes from a hybrid implementation-effectiveness study of the living well during pregnancy Tele-coaching program for women at high risk of excessive gestational weight gain.

BACKGROUND: Excess gestational weight gain (GWG) is associated with short-term perinatal complications and longer term cardiometabolic risks for mothers and their babies. Dietitian counselling and weight gain monitoring for women at risk of high pregnancy weight gain is recommended by clinical practice guidelines. However, face-to-face appointments, during a time with high appointment burden, can introduce barriers to engaging with care. Telephone counselling may offer a solution. The Living Well during Pregnancy (LWdP) program is a dietitian-delivered telephone coaching program implemented within routine antenatal care for women at risk of excess GWG. This program evaluation used a hybrid implementation-effectiveness design guided by the RE-AIM framework to report on the primary outcomes (reach, adoption, implementation, maintenance) and secondary outcomes (effectiveness) of the LWdP intervention. METHODS: The LWdP program evaluation compared data from women participating in the LWdP program with a historical comparison group (pregnant women receiving dietetic counselling for GWG in the 12 months prior to the study). The primary outcomes were described for the LWdP program. Between group comparisons were used to determine effectiveness of achieving appropriate GWG and pre and post intervention comparisons of LWdP participants was used to determine changes to dietary intake and physical activity. RESULTS: The LWdP intervention group (n = 142) were compared with women in the historical comparison group (n = 49). Women in the LWdP intervention group attended 3.4 (95% CI 2.9-3.8) appointments compared with 1.9 (95% CI, 1.6-2.2) in the historical comparison group. GWG was similar between the two groups, including the proportion of women gaining weight above the Institute of Medicine recommendations (70% vs 73%, p = 0.69). Within group comparison showed that total diet quality, intake of fruit and vegetables and weekly physical activity were all significantly improved from baseline to follow-up for the women in LWdP, while consumption of discretionary food and time spent being sedentary decreased (all p < 0.05). CONCLUSION: The LWdP program resulted in more women accessing care and positive improvements in diet quality, intuitive eating behaviours and physical activity. It was as effective as face-to-face appointments for GWG, though more research is required to identify how to engage women earlier in pregnancy and reduce appointment burden.

Do patients discharged from advanced practice physiotherapy-led clinics re-present to specialist medical services?

Objective The aim of the present study was to determine the rates of re-referral to specialist out-patient clinics for patients previously managed and discharged from an advanced practice physiotherapy-led service in three metropolitan hospitals. Methods A retrospective audit was undertaken of 462 patient cases with non-urgent musculoskeletal conditions discharged between 1 April 2014 and 30 March 2015 from three metropolitan hospitals. These patients had been discharged from the physiotherapy-led service without requiring specialist medical review. Rates and patterns of re-referral to specialist orthopaedic, neurosurgical, chronic pain, or rheumatology services within 12 months of discharge were investigated. Results Forty-six of the 462 patients (10.0%) who were managed by the physiotherapy-led service were re-referred to specialist medical orthopaedic, neurosurgical, chronic pain or rheumatology departments within 12 months of discharge. Only 22 of these patients (4.8%) were re-referred for the same condition as managed previously and discharged. Conclusions Ninety-five per cent of patients with non-urgent musculoskeletal conditions managed by an advanced practice physiotherapy-led service at three metropolitan hospitals did not re-present to access public specialist medical services for the same condition within 12 months of discharge. This is the first time that re-presentation rates have been reported for patients managed in advanced practice physiotherapy services and the findings support the effectiveness of these models of care in managing demand for speciality out-patient services. What is known about the topic? Advanced practice physiotherapy-led services have been implemented to address the needs of patients referred with non-urgent musculoskeletal conditions to hospital specialist out-patient services. Although this model is widely used in Australia, there has been very little information about whether patients managed in these services subsequently re-present for further specialist medical care. What does this paper add? This paper identifies that the majority (95%) of patients managed by an advanced practice physiotherapy-led service did not re-present for further medical care for the same condition within 12 months of discharge. What are the implications for practitioners? This paper supports the use of advanced practice physiotherapy-led services in the management of overburdened neurosurgical and orthopaedic specialist out-patient waiting lists.

Senior physiotherapy students as standardised patients for junior students enhances self-efficacy and satisfaction in both junior and senior students.

BACKGROUND: Standardised patients are used in medical education to expose students to clinical contexts and facilitate transition to clinical practice, and this approach is gaining momentum in physiotherapy programs. Expense and availability of trained standardised patients are factors limiting widespread adoption, and accessing clinical visits with real patients can be challenging. This study addressed these issues by engaging senior students as standardised patients for junior students. It evaluated how this approach impacted self-reported constructs of both the junior and senior students. METHODS: Learning activities for undergraduate physiotherapy students were developed in five courses (Neurology, Cardiorespiratory and three Musculoskeletal courses) so that junior students (Year 2 and 3) could develop skills and confidence in patient interview, physical examination and patient management through their interaction with standardised patients played by senior students (Year 4). Surveys were administered before and after the interactions to record junior students' self-reported confidence, communication, preparedness for clinic, and insight into their abilities; and senior students' confidence and insight into what it is like to be a patient. Satisfaction regarding this learning approach was surveyed in both the junior and senior students. RESULTS: A total of 253 students completed the surveys (mean 92.5% response rate). Across all courses, junior students reported a significant (all P < 0.037) improvement following the standardised patient interaction in their: preparedness for clinic, communication with clients, confidence with practical skills, and understanding of their strengths and weaknesses in relation to the learning activities. Senior students demonstrated a significant improvement in their confidence in providing feedback and insight into their own learning (P < 0.001). All students reported high satisfaction with this learning experience (mean score 8.5/10). CONCLUSION: This new approach to peer-assisted learning using senior students as standardised patients resulted in positive experiences for both junior and senior students across a variety of physiotherapy areas, activities, and stages within a physiotherapy program. These findings support the engagement of senior students as standardised patients to enhance learning within physiotherapy programs, and may have application across other disciplines to address challenges associated with accessing real patients via clinical visits or utilising actors as standardised patients.

The economic impact of rostering junior doctors to triage to assist nursing staff in the early part of the patient journey through the emergency department.

OBJECTIVE: This study aims to determine whether redeploying junior doctors to assist at triage represents good value for money and a good use of finite staffing resources. METHODS: We undertook a cost-minimisation analysis to produce new evidence, from an economic perspective, about the costs associated with reallocating junior doctors in the emergency department. We built a decision-analytic model, using a mix of prospectively collected data, routinely collected administrative databases and hospital costings to furnish the model. To measure the impact of uncertainty on the model's inputs and outputs, probabilistic sensitivity analysis was undertaken, using Monte Carlo simulation. RESULTS: The mean costs for usual care were $27,035 (95% CI $27,016 to $27,054), while the mean costs for the new model of care were $25,474, (95% CI $25,453 to $25,494). As a result, the mean difference was -$1,561 (95% CI -$1,533 to -$1,588), with the new model of care being a less costly approach to managing staffing allocations, in comparison to the usual approach. CONCLUSION: Our study shows that redeploying a junior doctor from the fast-track area of the department to assist at triage provides a modest reduction in cost. Our findings give decision-makers who seek to maximise benefit from their finite budget, support to reallocate personnel within the ED.

Comparing fly-in fly-out and telehealth models for delivering advanced-practice physiotherapy services in regional Queensland: An audit of outcomes and costs.

INTRODUCTION: Recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities in Queensland, Australia remains a challenge. To overcome this barrier, two different service delivery models (Fly-In, Fly-Out (FIFO), Telehealth) were trialled by one regional facility. This study aims to describe the economic- and service-related outcomes of these two methods of service delivery. METHODS: A retrospective audit was conducted where two nine-week time periods were selected for each service delivery model. Outcomes of interests include patient demographics and case-mix, service utilisation, clinical actions, adverse events and costs. Net financial position for both models was calculated based upon costs incurred and revenue generated by service activity. RESULTS: A total of 33 appointment slots were recorded for each service delivery model. Patient case-mix was variable, where the Telehealth model predominately involved patients with musculoskeletal spinal conditions managed from a neurosurgical waiting list. Appointment slot utilisation and pattern of referral for further investigations were similar between models. No safety incidents occurred in either service delivery model. An estimated cost-savings of 13% for the Telehealth model could be achieved when compared to the FIFO model. DISCUSSION: Telehealth is a safe, efficient and viable option when compared to a traditional in-person outreach service, while providing cost-savings. Telehealth should be seen as a service delivery medium in which sustainable recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities can be achieved.

Implementation of the Living Well During Pregnancy Telecoaching Program for Women at High Risk of Excessive Gestational Weight Gain: Protocol for an Effectiveness-Implementation Hybrid Study.

BACKGROUND: Despite comprehensive guidelines for healthy gestational weight gain (GWG) and evidence for the efficacy of dietary counseling coupled with weight monitoring on reducing excessive GWG, reporting on the effectiveness of interventions translated into routine antenatal care is limited. OBJECTIVE: This study aims to implement and evaluate the Living Well during Pregnancy (LWdP) program in a large Australian antenatal care setting. Specifically, the LWdP program will be incorporated into usual care and delivered to a population of pregnant women at risk of excessive GWG through a dietitian-delivered telephone coaching service. METHODS: Metrics from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework will guide the evaluation in this hybrid effectiveness-implementation study. All women aged ≥16 years without pre-exiting diabetes with a prepregnancy BMI >25 kg/m2 and gaining weight above recommendations at <20 weeks' gestation who are referred for dietetic care during the 12-month study period will be eligible for participation. The setting is a metropolitan hospital at which approximately 6% of the national births in Australia take place each year. Eligible participants will receive up to 10 telecoaching calls during their pregnancy. Primary outcomes will be service level indicators of reach, adoption, and implementation that will be compared with a retrospective control group, and secondary effectiveness outcomes will be participant-reported anthropometric and behavioral outcomes; all outcomes will be assessed pre- and postprogram completion. Additional secondary outcomes relate to the costs associated with program implementation and pregnancy outcomes gathered through routine clinical service data. RESULTS: Data collection of all variables was completed in December 2020, with results expected to be published by the end of 2021. CONCLUSIONS: This study will evaluate the implementation of an evidence-based intervention into routine health service delivery and will provide the practice-based evidence needed to inform decisions about its incorporation into routine antenatal care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/27196.

Implementation of simulation modelling to improve service planning in specialist orthopaedic and neurosurgical outpatient services.

BACKGROUND: Advanced physiotherapist-led services have been embedded in specialist orthopaedic and neurosurgical outpatient departments across Queensland, Australia, to ameliorate capacity constraints. Simulation modelling has been used to inform the optimal scale and professional mix of services required to match patient demand. The context and the value of simulation modelling in service planning remain unclear. We aimed to examine the adoption, context and costs of using simulation modelling recommendations to inform service planning. METHODS: Using an implementation science approach, we undertook a prospective, qualitative evaluation to assess the use of discrete event simulation modelling recommendations for service re-design and to explore stakeholder perspectives about the role of simulation modelling in service planning. Five orthopaedic and neurosurgical services in Queensland, Australia, were selected to maximise variation in implementation effectiveness. We used the consolidated framework for implementation research (CFIR) to guide the facilitation and analysis of the stakeholder focus group discussions. We conducted a prospective costing analysis in each service to estimate the costs associated with using simulation modelling to inform service planning. RESULTS: Four of the five services demonstrated adoption by inclusion of modelling recommendations into proposals for service re-design. Four CFIR constructs distinguished and two CFIR constructs did not distinguish between high versus mixed implementation effectiveness. We identified additional constructs that did not map onto CFIR. The mean cost of implementation was AU$34,553 per site (standard deviation = AU$737). CONCLUSIONS: To our knowledge, this is the first time the context of implementing simulation modelling recommendations in a health care setting, using a validated framework, has been examined. Our findings may provide valuable insights to increase the uptake of healthcare modelling recommendations in service planning.

Balance recovery is compromised and trunk muscle activity is increased in chronic obstructive pulmonary disease.

Increased respiration in chronic obstructive pulmonary disease (COPD) requires greater abdominal muscle activation, which may impact on contribution of the trunk to postural control. This study aimed to determine whether recovery of balance from postural perturbations and trunk muscle activity differs in people with and without COPD before and/or after exercise. Electromyography (EMG) of the obliquus internus (OI) and externus (OE) abdominis, rectus abdominis (RA), erector spinae (ES) and deltoid muscles was recorded with surface electrodes during rapid shoulder flexion and extension. Time taken to regain baseline centre of pressure velocity (vCOP) and the number of postural adjustments following arm movement was calculated from force plate data. Time to recover balance in the direction of postural disturbance (anteroposterior vCOP) was longer in COPD, particularly more severe COPD, than controls. Mediolateral vCOP (perpendicular to the perturbation) and the number of postural adjustments did not differ between groups, but people with more severe COPD were less successful at returning their mediolateral vCOP to baseline. Abdominal muscle EMG was similar between groups, but controls had greater ES EMG during arm movements. Individuals with more severe COPD had greater OE and RA EMG both before and during arm movement compared to those with less severe COPD and controls. Following exercise, OE and ES EMG increased in people with less severe COPD. This study shows that severe COPD is associated with impaired ability to recover balance and greater trunk muscle activity during postural challenges. Augmented trunk muscle activity may limit the contribution of trunk movements to balance recovery and could contribute to increased falls risk.

Reduced inspiratory muscle endurance following successful weaning from prolonged mechanical ventilation.

STUDY OBJECTIVES: Respiratory muscle weakness and decreased endurance have been demonstrated following mechanical ventilation. However, its relationship to the duration of mechanical ventilation is not known. The aim of this study was to assess respiratory muscle endurance and its relationship to the duration of mechanical ventilation. DESIGN: Prospective study. SETTING: Tertiary teaching hospital ICU. PATIENTS: Twenty subjects were recruited for the study who had received mechanical ventilation for > or = 48 h and had been discharged from the ICU. MEASUREMENTS: FEV1, FVC, and maximal inspiratory pressure (P(I(max)) at functional residual capacity were recorded. The P(I(max)) attained following resisted inspiration at 30% of the initial P(I(max)) for 2 min was recorded, and the fatigue resistance index (FRI) [P(I(max)) final/P(I(max))initial] was calculated. The duration of ICU length of stay (ICULOS), duration of mechanical ventilation (MVD), duration of weaning (WD), and Charlson comorbidities score (CCS) were also recorded. Relationships between fatigue and other parameters were analyzed using the Spearman correlations (rho). RESULTS: Subjects were admitted to the ICU for a mean duration of 7.7 days (SD, 3.7 days) and required mechanical ventilation for a mean duration of 4.6 days (SD, 2.5 days). The mean FRI was 0.88 (SD, 0.13), indicating a 12% fall in P(I(max)), and was negatively correlated with MVD (r = -0.65; p = 0.007). No correlations were found between the FRI and FEV1, FVC, ICULOS, WD, or CCS. CONCLUSIONS: Patients who had received mechanical ventilation for > 48 h have reduced inspiratory muscle endurance that worsens with the duration of mechanical ventilation and is present following successful weaning. These data suggest that patients needing prolonged mechanical ventilation are at risk of respiratory muscle fatigue and may benefit from respiratory muscle training.

Case report: inspiratory muscle training in chronic critically ill patients--a report of two cases.

BACKGROUND AND PURPOSE: Inspiratory muscle weakness and fatigue has been documented following prolonged mechanical ventilation despite successful weaning from mechanical ventilation. This report describes the application of inspiratory muscle training in two patients following successful discharge from an intensive care unit (ICU) after prolonged mechanical ventilation. METHODS: Both patients undertook inspiratory muscle training in conjunction with standard physiotherapy rehabilitation. RESULTS: Improvements in inspiratory muscle strength and endurance, exercise tolerance and functional performance following twice-daily inspiratory muscle training were recorded. In both cases, an improvement in maximal inspiratory pressure (MIP) and maximal tolerated inspiratory load (MIP(load)) was found following training. CONCLUSION: These positive results indicate further research is needed to investigate the effect of inspiratory muscle training on respiratory function, exercise tolerance and functional performance, for the possible inclusion of inspiratory muscle training into the physiotherapy management of patients following prolonged mechanical ventilation.