Comparing Perspectives of Patients, Caregivers, and Clinicians on Heart Failure Management.

BACKGROUND: Although substantial effort has been devoted to reducing readmissions among heart failure (HF) patients, little is known about factors identified by patients and caregivers that may contribute to readmissions. The goal of this study was to compare the perspectives of HF patients, their caregivers, and their care team on HF management and hospital admissions. Understanding these perspectives may lead to better strategies for improving care during the post-hospital transition and for reducing preventable readmissions. METHODS AND RESULTS: We performed freelisting, an anthropologic technique in which participants list items in response to a question, with hospitalized HF patients (n = 58), their caregivers (n = 32), and clinicians (n = 67). We asked about home HF management tasks, difficulties in managing HF, and perceived reasons for hospital admission. Results were analyzed with the use of Anthropac. Salience indices (measures of the most important words for defining the domain of interest) were calculated. Patients and clinicians described similar home HF management tasks, whereas caregivers described tasks related to activities of daily living. Clinicians cited socioeconomic factors as challenges to HF management, whereas patients and caregivers cited limited functional status and daily activities. When asked about reasons for hospitalization, patients and caregivers listed distressing symptoms and illness, whereas clinicians viewed patient behaviors to be primarily responsible for admission. CONCLUSIONS: These findings highlight that although some similarities exist, there are important differences among patients, caregivers, and clinicians in how they perceive the challenges of HF management and reasons for readmission. Understanding these differences may be critical to developing strategies to reduce readmissions.

An Exploratory Study of Employers' Attitudes Towards a Clinical Doctorate in Genetic Counseling.

Creation of an advanced degree in genetic counseling has been considered since the early 1980s. The Genetic Counseling Advanced Degree Task Force (GCADTF) was convened in 2012 to formally explore the potential suitability of a clinical doctorate (ClinD), though employer perspectives of advanced training were not part of the discussion. The conclusion of this group was that the field was not ready to move to an entry-level clinical doctorate at this time but that further education and research among other stakeholders was necessary (Nagy et al. 2014). In this study, we describe employers' perspectives on developing a clinical doctorate in genetic counseling based upon thirty audio-recorded semi-structured phone interviews that were transcribed verbatim and qualitatively analyzed. Overall, employers expressed concerns regarding the economic viability of ClinD training but envisioned expanded roles for genetic counselors (especially in areas of education and research) and enhanced credibility. While some employers reported that they would provide flexibility and tuition assistance for acquisition of a ClinD, for many employers, support was contingent on perceived value of the degree. Some employers were not clear about the difference between a ClinD and a PhD, suggesting that there is a need for educating employers about advanced degree options for the genetic counseling field. Future research could include investigating employer attitudes about market needs, envisioned roles, and compensation formulas for counselors with a ClinD or other forms of advanced training.

Patient Perspectives of Acute Pain Management in the Era of the Opioid Epidemic.

STUDY OBJECTIVE: To inform the development of interventions that could improve patient engagement around the risks and benefits of alternative approaches to pain management in the emergency department (ED), we seek to capture the perspectives and experiences of patients treated for pain in this setting. METHODS: Three trained interviewers conducted semistructured open-ended telephone interviews with patients discharged from a single urban academic ED after presenting with acute pain related to fracture, renal colic, or musculoskeletal back injury. We recruited subjects until achieving thematic saturation according to periodic review of the interview transcripts. Interviews were audio recorded, professionally transcribed, and uploaded into QSR NVivo (version 10.0) for coding and analysis using modified grounded theory. An interdisciplinary team double coded the data and convened to review emerging themes, ensure interrater reliability, and establish consensus on discrepancies. RESULTS: We had 23 completed subject interviews, the majority of which were women. Interrater reliability for coding exceeded 90%. The major themes elicited centered on domains of patient awareness of the potential for opioid dependence and patient-provider communication relating to pain management. From the patient perspective, emergency physicians typically do not present alternative pain management options or discuss the risks of opioid dependence. Patients with negative experiences related to pain management describe deficiencies in patient-provider communication leading to misunderstanding of clinical diagnoses, fragmentation of care among their health care providers, and a desire to be involved in the decisionmaking process around their pain management. Patients with positive experiences commented on regular communication with their care team, rapid pain management, and the empathetic nature of their care providers. Patients communicate fears about the risks of opioid addiction, beliefs that following a prescribed opioid regimen is protective of developing opioid dependence, and an understanding of the broader tensions that providers face relating to the prescription of opioid therapy. CONCLUSION: Patients identified a deficit of communication around opioid risk and pain management options in the ED.

Optimizing the patient handoff between emergency medical services and the emergency department.

STUDY OBJECTIVE: Patient handoffs are known as high-risk events for medical error but little is known about the professional, structural, and interpersonal factors that can affect the patient transition from emergency medical services (EMS) care to the emergency department (ED). We study EMS providers' perspectives to generate hypotheses to inform and improve this handoff. METHODS: We conducted focus groups with EMS providers recruited at 3 national and regional conferences from January to March 2011 until theme saturation was reached; 7 focus groups were conducted with 48 EMS providers. Deidentified transcripts and notes were entered into QSR NVivo, coded, and analyzed to identify themes. RESULTS: EMS providers identified themselves as advocates for their patients during the challenging EMS-to-ED handoffs. Providers identified normative challenges they encounter in their communications with hospital staff, and features of EMS and hospital protocols that either facilitate or undermine effective handoffs from the out-of-hospital environment to the ED. They identified 4 key potential ways to improve the structure and process of the handoff: (1) communicate directly with the ED provider responsible for the patient's care; (2) increase interdisciplinary feedback, transparency, and shared understanding of scope of practice between out-of-hospital and hospital-based providers; (3) standardize some (but not all) aspects of the handoff; and (4) harness technology to close gaps in information exchange. CONCLUSION: These exploratory findings suggest that the effect of increasing EMS interactions with emergency physicians, standardizing handoff processes, and fostering interprofessional learning represent opportunities for future study and may serve as potential solutions for the high-risk EMS-ED patient transition.

How, why, and for whom do emergency medicine providers use prescription drug monitoring programs?

OBJECTIVE: The prescription opioid epidemic is currently responsible for the greatest number of unintentional deaths in the United States. One potential strategy for decreasing this epidemic is implementation of state-based Prescription Drug Monitoring Programs (PDMPs), which are designed for providers to identify patients who "doctor shop" for prescriptions. Emergency medicine physicians are some of the most frequent PDMP users and opioid prescribers, but little is known about how they actually use PDMPs, for which patients, and for what reasons. METHODS: We conducted and transcribed semistructured qualitative interviews with 61 physicians at a national academic conference in October 2012. Deidentified transcripts were entered into QSR NVivo 10.0, coded, and analyzed for themes using modified grounded theory. RESULTS: There is variation in pattern and frequency of PDMP access by emergency physicians. Providers rely on both structural characteristics of the PDMP, such as usability, and also their own clinical gestalt impression when deciding to use PDMPs for a given patient encounter. Providers use the information in PDMPs to alter clinical decisions and guide opioid prescribing patterns. Physicians describe alternative uses for the databases, such as improving their ability to facilitate discussions on addiction and provide patient education. CONCLUSION: PDMPs are used for multiple purposes, including identifying opioid misuse and enhancing provider-patient communication. Given variation in practice, standards may help direct indication and manner of physician use. Steps to minimize administrative barriers to PDMP access are warranted. Finally, alternative PDMP uses should be further studied to determine their appropriateness and potentially expand their role in clinical practice.

How do physicians adopt and apply opioid prescription guidelines in the emergency department? A qualitative study.

STUDY OBJECTIVE: An increase in prescriptions for opioid pain medications has coincided with increasing opioid overdose deaths. Guidelines designed to optimize opioid prescriptions written in the emergency department have been implemented, with substantial controversy. Little is known about how physicians perceive and apply these guidelines. We seek to identify key themes about emergency physicians' definition, awareness, use, and opinions of opioid-prescribing guidelines. METHODS: We conducted semistructured qualitative interviews with a convenience sample of 61 emergency physicians attending the American College of Emergency Physicians Scientific Assembly (October 2012, Denver, CO). Participants varied with respect to age, sex, geographic region, practice setting, and years of practice experience. We analyzed the interview content with modified grounded theory, an iterative coding process to identify patterns of responses and derive key themes. The study team examined discrepancies in the coding process to ensure reliability and establish consensus. RESULTS: When aware of opioid-prescribing guidelines, emergency physicians often defined them as policies developed by individual hospitals that sometimes reflected guidelines at the state or national level. Guidelines were primarily used by physicians to communicate decisions to limit prescriptions to patients on discharge rather than as tools for decisionmaking. Attitudes toward guidelines varied with regard to general attitudes toward opioid medications, as well as the perceived effects of guidelines on physician autonomy, public health, liability, and patient diversion. CONCLUSION: These exploratory findings suggest that hospital-based opioid guidelines complement and occasionally supersede state and national guidelines and that emergency physicians apply guidelines primarily as communication tools. The perspectives of providers should inform future policy actions that seek to address the problem of opioid abuse and overdose through practice guidelines.

Aggressive Management of a Bilateral Chylothorax Complicating an Orthotopic Heart-Kidney Transplantation.

Chylothorax after an orthotopic heart transplant is a rare but potentially detrimental occurrence. This is the first reported case of bilateral chylothorax complicating a heart-kidney transplant patient. No universally accepted protocol exists for the management of chylothorax in general population, let alone the immunocompromised transplant patient. This case presents unique challenges to the management of postoperative chylothorax given heart-kidney transplant's effect on the patient's volume status and immunocompromised state. We make the argument for aggressive treatment of chylothorax in an immunocompromised heart-kidney transplant patient to limit complications in a patient population predisposed to infection.

Missing lung nodule? Intra-operative contingency plan with O-arm imaging: a case report.

Despite the availability of various modalities to locate small non-palpable pulmonary nodules during minimally invasive thoracoscopic surgery, precise lung nodule resection remains a challenge. Pre-operative localization techniques add additional time, expense, and complication rate. Intra-operative localization methods, such as ultrasound, may be a real-time solution, but challenges remain with visualizing deep parenchyma lesions and operator-dependent use. Many thoracoscopic wedge resections are performed using a combination of pre-operative imaging and intra-operative landmarks. Although usually cost and time-efficient, the problem occurs when a wedge resection is performed, and the nodule is not within the specimen. This case report describes the use of the O-arm Surgical Imaging System, a full-rotation imaging system that provides three-dimensional cone-beam imaging, in an 81-year-old male patient with a solid 8 mm left lower lobe lung nodule. After two unsuccessful wedge resections, we used the O-arm and finally resected the nodule with a negative surgical margin. The O-arm provided instant feedback regarding the nodule status, allowing a standard thoracoscopy room to function as a hybrid operating room without the need to reposition the patient. Rather than convert to a thoracotomy, proceed to a larger resection, or experience a missed nodule, the O-arm proved to be a helpful intra-operative tool to find a missing lung nodule.

Aggressive Management of a Bilateral Chylothorax Complicating an Orthotopic Heart-Kidney Transplantation

ABSTRACT Chylothorax after an orthotopic heart transplant is a rare but potentially detrimental occurrence. This is the first reported case of bilateral chylothorax complicating a heart-kidney transplant patient. No universally accepted protocol exists for the management of chylothorax in general population, let alone the immunocompromised transplant patient. This case presents unique challenges to the management of postoperative chylothorax given heart-kidney transplant's effect on the patient's volume status and immunocompromised state. We make the argument for aggressive treatment of chylothorax in an immunocompromised heart-kidney transplant patient to limit complications in a patient population predisposed to infection.

What do patients say about emergency departments in online reviews? A qualitative study.

BACKGROUND: Patients have adopted web-based tools to report on the quality of their healthcare experiences. We seek to examine online reviews for US emergency departments (EDs) posted on Yelp, a popular consumer ratings website. METHODS: We conducted a qualitative analysis of unstructured, publicly accessible reviews for hospitals available on http://www.yelp.com. We collected all reviews describing experiences of ED care for a stratified random sample of 100 US hospitals. We analysed the content of the reviews using themes derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) inpatient care survey. We also used modified grounded theory to iteratively code the text of the reviews, identifying additional themes specific to emergency care. The data were double-coded, and discrepancies were evaluated to ensure consensus. RESULTS: Of the 1736 total reviews, 573 (33%) described patient experiences involving the ED. The reviews contained several themes assessed by the HCAHPS survey, including communication with nurses, communication with doctors, and pain control. The reviews also contained key themes specific to emergency care: waiting and efficiency; decisions to seek care in the ED; and events following discharge, including administrative difficulties. CONCLUSIONS: These exploratory findings suggest that online reviews for EDs contain similar themes to survey-based assessments of inpatient hospital care as well as themes specific to emergency care. Consumer rating websites allow patients to provide rapid and public feedback on their experience of medical care. Web-based platforms may offer a novel strategy for assessing patient-centred quality in emergency care.

Parent and provider perspectives on procedural care for children with autism spectrum disorders.

OBJECTIVE: Children with autism spectrum disorders (CWASDs) have more difficulty tolerating hospital procedures than many other children. The aim of this study was to identify parent and provider perspectives on barriers and facilitators to procedural care for CWASDs. METHODS: Semistructured interviews were conducted with medical staff and parents of CWASDs. Those parents whose child with autism required a procedure in a tertiary care sedation unit and those whose child was enrolled in autismMatch (a research registry for individuals with autism) were recruited. Staff providing direct patient care in the tertiary care sedation unit were recruited. Participants were asked open-ended questions about factors contributing to or interfering with successful completion of medical procedures for CWASDs. Interviews were audio-recorded, transcribed verbatim, coded, and analyzed using modified grounded theory techniques. RESULTS: Twenty mothers and 20 medical staff members were interviewed. Participants described 2 domains essential to care of CWASDs but in which barriers existed: (1) productive interactions between providers and families, largely dependent on advanced preparation and (2) modifications to healthcare organization and delivery in the areas of patient flow and clinical environment. Individualized care is essential to quality care in both domains. CONCLUSIONS: Children with autism spectrum disorders require individualized interventions to maximize the quality of procedural care. However, many hospitals and providers are not sufficiently equipped to accommodate these children's needs. This study suggests that targeted improvements in preparation and communication between providers and families as well as modifications in patient flow and clinical environments have the potential to improve the quality and successful completion of procedures.

Barriers to calling for urgent assistance despite a comprehensive pediatric rapid response system.

BACKGROUND: Rapid response systems (RRSs) aim to identify and rescue hospitalized patients whose condition is deteriorating before respiratory or cardiac arrest occurs. Previous studies of RRS implementation have shown variable effectiveness, which may be attributable in part to barriers preventing staff from activating the system. OBJECTIVE: To proactively identify barriers to calling for urgent assistance that exist despite recent implementation of a comprehensive RRS in a children's hospital. METHODS: Qualitative study using open-ended, semistructured interviews of 27 nurses and 30 physicians caring for patients in general medical and surgical care areas. RESULTS: The following themes emerged: (1) Self-efficacy in recognizing deteriorating conditions and activating the medical emergency team (MET) were considered strong determinants of whether care would be appropriately escalated for children in a deteriorating condition. (2) Intraprofessional and interprofessional hierarchies were sometimes challenging to navigate and led to delays in care for patients whose condition was deteriorating. (3) Expectations of adverse interpersonal or clinical outcomes from MET activations and intensive care unit transfers could strongly shape escalation-of-care behavior (eg, reluctance among subspecialty attending physicians to transfer patients to the intensive care unit for fear of inappropriate management). CONCLUSIONS: The results of this study provide an in-depth description of the barriers that may limit RRS effectiveness. By recognizing and addressing these barriers, hospital leaders may be able to improve the RRS safety culture and thus enhance the impact of the RRS on rates of cardiac arrest, respiratory arrest, and mortality outside the intensive care unit.

A hybrid effectiveness-implementation trial of an evidence-based exercise intervention for breast cancer survivors.

BACKGROUND: The primary aims of this hybrid Type 1 effectiveness-implementation trial were to quantitatively assess whether an evidence-based exercise intervention for breast cancer survivors, Strength After Breast Cancer, was safe and effective in a new setting and to qualitatively assess barriers to implementation. METHODS: A cohort of 84 survivors completed measurements related to limb volume, muscle strength, and body image at baseline, 67 survivors completed measurements 12 months later. Qualitative methods were used to understand barriers to implementation experienced by referring oncology clinicians and physical therapists who delivered the program. RESULTS: Similar to the efficacy trial, the revised intervention demonstrated safety with regard to lymphedema, and led to improvements in lymphedema symptoms, muscular strength, and body image. Comparison of effects in the effectiveness trial to effects in the efficacy trial revealed larger strength increases in the efficacy trial than in the effectiveness trial (P < .04), but few other differences were found. Qualitative implementation data suggested significant barriers around intervention characteristics, payment, eligibility criteria, the referral process, the need for champions (ie, advocates), and the need to adapt during implementation of the intervention, which should be considered in future dissemination and implementation efforts. CONCLUSIONS: This trial successfully demonstrated that a physical therapy led strength training program for breast cancer survivors can be implemented in a community setting while retaining the effectiveness and safety of the clinical trial. However, during the translation process, strategies to reduce barriers to implementation are required. This new program can inform larger scale dissemination and implementation efforts.

Beyond statistical prediction: qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety.

BACKGROUND: Early warning scores (EWSs) assign points to clinical observations and generate scores to help clinicians identify deteriorating patients. Despite marginal predictive accuracy in retrospective datasets and a paucity of studies prospectively evaluating their clinical effectiveness, pediatric EWSs are commonly used. OBJECTIVE: To identify mechanisms beyond their statistical ability to predict deterioration by which physicians and nurses use EWSs to support their decision making. DESIGN: Qualitative study. SETTING: A children's hospital with a rapid response system. PARTICIPANTS: Physicians and nurses who recently cared for patients with false-positive and false-negative EWSs (score failures). INTERVENTION: Semistructured interviews. MEASUREMENTS: Themes identified through grounded theory analysis. RESULTS: Four themes emerged among the 57 subjects interviewed: (1) The EWS facilitates safety by alerting physicians and nurses to concerning changes and prompting them to think critically about deterioration. (2) The EWS provides less-experienced nurses with vital sign reference ranges. (3) The EWS serves as evidence that empowers nurses to overcome barriers to escalating care. (4) In stable patients, those with baseline abnormal physiology, and those experiencing neurologic deterioration, the EWS may not be helpful. CONCLUSIONS: Although pediatric EWSs have marginal performance when applied to datasets, clinicians who recently experienced score failures still considered them valuable to identify deterioration and transcend hierarchical barriers. Combining an EWS with a clinician's judgment may result in a system better equipped to respond to deterioration than retrospective data analyses alone would suggest. Future research should seek to evaluate the clinical effectiveness of EWSs in real-world settings.